(Right-Click on this form to print it out)

CROSSROADS HOUSE Volunteer Application   Name____________________________________________________Date________ Address______________________________________________________________ _____________________________________________________________________ Sex M__F__ Phone_(H)____________________(W)_______________________DOB__________ 1. Present/past occupation and/or employer. Please include occupational skills. ____________________________________________________________________ 2. Have you worked as a Volunteer before? Yes___No___ If yes, please list organizations, length of involvement and duties. ____________________________________________________________________ ____________________________________________________________________ 3. Why do want to volunteer at Crossroads House? ____________________________________________________________________ ____________________________________________________________________ 4. Have you ever been a primary caregiver to someone who was dying or chronically ill? Please explain. ____________________________________________________________________ ____________________________________________________________________ 5. What special talents/abilities/strengths do you feel that you have that would be an asset to Crossroads house? ____________________________________________________________________ ____________________________________________________________________ 6. What are you favorite hobbies/fun interests? ____________________________________________________________________ 7. Have you had any experience with death and dying or other types of personal loss? How recently? ____________________________________________________________________ ____________________________________________________________________ 8. Do you have any health problems or physical limitations which would restrict the work that you can do? ____________________________________________________________________ 9. Please check the components of a Crossroads House volunteer that you would be interested in. _____Physical Care (direct patient) _____Emotional/Spiritual support for resident and family or friends _____Household needs _____Transportation/driving _____Maintenance of grounds _____Maintenance of equipment/appliances _____Food Shopping _____Organizational help (fundraising, P.R., phone work, mailings,etc.) _____other ______________________________________________ OUR IDEAL IS TO HAVE A 4 HOUR TIME COMMITMENT EACH WEEK FOR EACH VOLUNTEER! 10. How often can you be available for volunteering? ____________________________________________________________________ 11. During which times can you be available_____8am-12N;_____12N-4pm; _____4pm-8pm; _____8pm-12MN; _____8pm-8am; _____12MN-8am. 12. Please share any concerns/fears/apprehensions that you may have that we can help you with in dealing with the terminally ill. ____________________________________________________________________ ____________________________________________________________________ 13. Are there any other things you would like to tell us about yourself? ____________________________________________________________________ ____________________________________________________________________ 14. Please list 3 references include: NAME, ADDRESS, PHONE# ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

PLEASE RETURN COMPLETED APPLICATION TO:

Crossroads House

PO Box 403

Batavia, N.Y. 14020