Burke Hospice Volunteer Application

1721 Enon Road
Valdese, NC 28690
www.burkehospice.org

Burke Hospice Volunteer Application for Adults Age 19+

Burke Hospice is always seeking volunteers to help fulfill our mission. Please fill in the information below to indicate how you would like to become involved. For more information on volunteering, contact our Volunteer Manager, Merri Rudisill, at 828/879-1601 during business hours, or email volunteer@burkehospice.org

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Postal Code *

Primary Phone *

May we contact you at work? *

Yes

Work Phone

Best Time to Contact *

Email Address

Birthdate (MM/DD/YY): *

NOTE: If you are between 14 and 18 years of age, please complete our VolunTEEN application.

Have you previously done volunteer work for this organization? *

Yes

Emergency Contact *

Relationship *

Phone Number *

Do you have a valid driver's license? *

Yes

Have you ever been convicted of a criminal offense? *

Yes

If yes, please explain:

Have you experienced the death of a loved one within the last year? *

Yes

If yes, please explain:

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Burke Hospice & Palliative Care | 828/874-HOPE