Volunteers - Application

Gaston Hospice and Grief Counseling Services

First Name:
Last Name:
Address:
City:
Zip:
Home Phone:  (Ex: 704-555-5555)
Work Phone:  (Ex: 704-555-5555)
E-mail Address:
Employment:
Position:
Hours:
Date of Birth:  

VOLUNTEER INTERESTS

Why are you interested in taking the Hospice Volunteer course?
Hospice utilizes volunteers in many areas. What are your interests? (Please check all that apply.)


 

EXPERIENCE

Please list previous volunteer experience (organization, location, dates, hours served, type of work).
List any other experiences or skills related to your volunteer interests:
What experiences have you had with people who are seriously ill?
Do you or does anyone in your family currently have cancer or a serious illness?
Have you had a death in the family in the past twelve months? If so, can you please elaborate?
Please list which areas you prefer to volunteer in (i.e. Belmont, Bessemer City, Cherryville, Cramerton, Dallas, Lowell, McAdenville, Mt. Holly, Stanley, etc.)

REFERENCES (No Relatives)

Reference #1
Name:
Address:
Phone:  (Ex: 704-555-5555)
Reference #2
Name:
Address:
Phone:  (Ex: 704-555-5555)
Reference #3
Name:
Address:
Phone:  (Ex: 704-555-5555)

Disabilities or Special Needs:
Have you ever been convicted of any crime other than a traffic violation?
If yes, explain:

This information will be kept confidential. It will help us in making your volunteer experience with Gaston Hospice more rewarding. Please feel free to call us at (704) 861-8405 if you have any questions or need additional information.

Gaston Hospice Services

Gaston Hospice is a local, non-profit healthcare organization that cares for people who have a life-limiting illness that is no longer responding to curative treatment. Hospice care enables these patients to live at home as fully as possible. Hospice puts both patient and family at the center of care planning.

Our Services Include:

- Pain and symptom management
- Assistance with financial and legal issues from a medical social worker
- Emotional and spiritual support from licensed counselors and chaplains
- Certified nursing assistants to help with personal care
- Volunteers to help provide companionship, run errands, etc.
- Respite care when family caregivers need a break
- Medications, equipment and supplies
- Grief support for loved ones

We Provide Our Services:

- In the home
- In the Robin Johnson House
- In the long term care facility
- In the hospital

Gaston Hospice serves any resident of Gaston County and the surrounding area who has been diagnosed with a life expectancy of six months or less. Services are provided regardless of diagnosis or ability to pay.

More Information

To find out more about about Gaston Hospice, stop by our office (directions), contact us online, or by phone at: 704.861-8405

Mailing address:
Gaston Hospice
PO Box 3984
Gastonia NC 28054
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