Volunteer Application Form « Assisi Hospice

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Volunteer Application Form

Making a real difference to the lives of our patients.
Join us by being a volunteer.

Kindly complete and submit the volunteer form.

Please complete using block letters. Information given on this form is confidential.

1. PERSONAL PARTICULARS

Full Name: (according to NRIC or Passport)

NRIC:

Address:

Postal Code:

Office Phone:

Residence Phone:

Mobile Phone:

Email Address:

Fax:

Date of Birth:

Place of Birth:

Sex:

male
Female

Marital Status:

Race:

Religion:

Occupation (Student to indicate level):

Current Work/Voluntary Experience:

2. BACK CARE STATEMENT

Have you ever suffered from any back or musculoskeletal problems? Yes No

General Health: Are you generally in good health? Yes No

Are you taking any long term medication? Yes No

Current Work/Voluntary Experience:


Are you a Car Owner? Yes No

Are you willing to use your Car? Yes No

Have you completed any course/training that might be used here? Yes No

Name of course/training:		Year taken:


Can communicate in
English Mandarin Malay Tamil
Others


Can speak in Dialect? Yes No
Please list here:


Can write in
English Mandarin Malay Tamil

3. IF YOU ARE UNDER 18

Name of Parent:

Relationship:

Contact No – Office:

Residence Phone:

Mobile Phone:

Is your parent/s aware of this application?
Yes
No

4. PREFERENCE OF VOLUNTARY SERVICE

Ward Day Centre (Adults) Day Centre (Children) Ad-Hoc

Day’s Available:
Mon Tues Thurs Fri Sat Sun

What will be your frequency of commitment:
Weekly Bi-Weekly Monthly

How long will be able to commit as a volunteer:
Months Years Flexible Daytime Weekends Weekdays Evenings

Please tick the areas of volunteering you are interested in:
Patient (Pt) Care Befriending Flexible Organise outings Provide Podiatry Care Conduct Exercises Conduct Arts & Crafts Accompany pt to hospital Organise Monthly Birthdays Wheel pt to the garden Computer Work Drama for kids Office work Provide Dental Care Gardening Volunteer Driver Maintaining & Cleaning equipments Tutoring Pre-School Teaching
Others


How did you hear about Assisi Hospice ?
Media Friends Others

Please give the details of a referee (not relations) whom we may contact for references.
Person of Reference:		Company:


Email Address:		Contact:

Address:

5. DECLARATION

I declare that the particulars provided by me are true and correct to the best of my knowledge and belief. I understand that if I willfully suppressed any material facts or provide false information, my employment will be terminated, and I may be subjected to criminal prosecution in accordance with the laws of Singapore.

Type in verification code below:

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Assisi Hospice | 820 Thomson Road Singapore 574623 | Phone: 6347 6446
This website is developed with co-funding support from the VWOs-Charities Capability Fund (VCF)

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