Contact Info

First Name* Last Name* Middle

Street Address* City* Zip* County*

Home Phone:
Work Phone:
Cell Phone:

Your Email*:

Cell Phone Provider*:

How do you prefer to be contacted? Home PhoneWork PhoneCell PhoneEmail

Employment

Current or former occupation:
Current or former employer:

How did you hear about Unity?

Why do you want to volunteer for Unity?

Describe any personal experience you have had with serious illness or loss.

Have you had a loved one on Unity's program?

Specialized Training/Education/Skills/Work Experience:

Current/Previous Volunteer Experience:

Special Interests/Hobbies (music/art/cards, etc.):

Are you able to make a one-year commitment to volunteering with Unity? YesNo

If no, what commitment are you able to make?

Generally I am available to volunteer (check all that apply):
morningsafternoonseveningsweekdaysweekends

Generally, what type of work are you drawn to? (check all that apply)
Patient/Family CareOffice AssistancePhone Call AssistanceFundraising EventsCommunity OutreachUnity Resale Shoppe, LLCJack and Engrid Meng Hospice ResidenceVeteran to Veteran ProgramCreative Projects (sew, knit/crochet)

To become a Unity Volunteer, each individual must go through a day-long orientation. Please indicate which days you are able to attend:
WeekdaysSaturdays

Special Notes:

Are you a year-round resident of Wisconsin?
YesNo

If no, where do you reside outside of Wisconsin?

Emergency Contacts

First Contact Name

Phone Name

Relationship

Second Contact Name

Phone Name

Relationship

References

Please do not include relatives

Reference One Name
Phone
Years known

Reference Two Name
Phone
Years known

Military History

Did you serve in the military?
YesNo

If yes, in which branch of the military did you serve?
Air ForceArmyCoast GuardMarinesMerchant Marines during WWIINavyReservist or National Guard Member

If yes, in which war era or period of service did you serve?
Afghanistan/Iraq (OEF/OIF)Cold WarGulf WarKoreaPeace TimeVietnamWWIWWII

Other war era or period of service not mentioned above?

Signature

I hereby certify that the answers provided by me are true and correct to the best of my knowledge. I also understand that every applicant will be required to pass a background check and attend orientation prior to becoming an active volunteer. Checking "I agree" below confirms my electronic signature.

I agree