Camp Chimaqua Volunteer Application - Hospice & Community Care

Thank you for your interest in becoming a volunteer for Hospice & Community Care. We appreciate your time in completing this application. If you have any questions, we can be reached at (717) 735-2466 or jhoran@hospicecommunty.org.

Name*

First Last

Home Address*

Street Address City State ZIP Code

Primary Phone*

Alternate Phone*

Email*

Are you already a volunteer with HCC?

Yes

EMERGENCY NOTIFICATION

Name*

Phone*

Relationship*

Address*

Street Address City State ZIP Code

EMPLOYMENT

Employment*

Not Applicable

Retired

Full Time

Part Time

Year Retired*

If retired, list year

Company*

Phone

If still employed, list work telephone if okay to receive calls.

SKILLS AND INTERESTS

Secondary Education and Special Training

Degree?*

Yes

Year*

Year

Other

Special Skills and Interests

Other

Other – please list

Military Service Branch*

Military Service Branch

Foreign Language*

Foreign Language

Have you had other volunteer experiences?*

Yes

Volunteer Role(s)*

Volunteer Role(s)

Agency*

Agency

Dates Volunteered*

Dates Volunteered

Activities*

Activities

Hobbies and Activities*

Community Clubs, Etc.

Do you have your own transportation?*

Yes

Have you ever been convicted of a crime?*

Yes

Crime Description*

If yes, please explain

How are you interested in helping?*

Adult Buddy

Day Staff

Day Staff Availability

Friday

Saturday

Sunday

Adult T-Shirt Size*

Briefly explain why you want to become a Camp volunteer.*

Have you ever attended camp as a child or as an adult camp counselor?*

Yes

If so, please elaborate.*

If so, please elaborate.

Describe any direct experience you've had assisting children or adults who are coping with the loss of a loved one.

Describe any experiences you've had working with children.

As we think about your involvement with camp, it is helpful to understand how you have been impacted by illness, death or other losses in you own life. Please elaborate below.

When we match Buddies and campers, it is helpful to know the interests of our volunteers. Please tell us about your interests — such as favorite sports, movies/tv shows, special interests, hobbies, etc...*

What do you believe you have to offer a grieving child?*

Is there a specific age range that you are not comfortable working with?

Is there any kind of death/type of loss that makes you uncomfortable?

Do you have any other concerns or significant information we should know?

LOSS HISTORY

Current Bereavement Support*

Are you currently receiving bereavement support from Hospice & Community Care?

Yes

Type of Support*

If "yes" please describe the type of support, including attendance at any type of Pathways support group.

REFERENCES

Please list 3 personal references (non-family) that support your desire to serve as a Hospice volunteer.

Name*

Relationship*

Phone*

Email*

Name*

Relationship*

Phone*

Email*

Name*

Relationship*

Phone*

Email*

Your signature indicates your willingness to allow us to check references, and also attests to the truthfulness of this information.

Signature*