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Volunteer Interest Form

Please complete and submit this form or contact the following people if you are interested in becoming a Coastal Hospice volunteer or would like more information:

Judy Hunt-Harris
jhuntharris@coastalhospice.org
(410) 742-8732 x107 or (800) 780-7886

Name*
Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email*
We would like to recognize your birthday if you care to share the date:
I would like to become actively involved in the following (please check all that apply): Coastal Hospice at the Lake
    Clerical/Reception
    Patient Care
Mailings
Office Assistance
    Computer
    Phones
    Filing
Patient/Family Support
    Assigned to a patient for ongoing needs
    Assigned to a patient for a single visit or short term needs
    Children
    Prefer non-smoking
    Prefer no pets
Transportation/Deliveries
    I will travel outside the country in which I live
Bereavement
Special Events (for example, Geranium Sale or Spring Party)
Community Education/Health Fairs/etc.
Hospitality/Prepare Refreshments
Other (please specify below)
Special Skills or Qualities Pick-up Truck
Foreign language (please specify below)
Sing
Crafts (please specify below)
Play an Instrument (please specify below)
Other (please specify below)
Available:
Morning
Afternoon
Evening		 MON



 TUE


 WED


 THU


 FRI


 SAT


 SUN


Please provide us with any details or comments you may have:




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2604 Old Ocean City Road | Salisbury, MD 21804 | 410-742-8732 | Fax 410-548-5669
PO Box 1733 | Salisbury, MD 21802

Coastal Hospice is a 501(c3) non-profit organization that relies on charitable support to provide its programs and services.

Copyright © 2010 Coastal Hospice, All Rights Reserved
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