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Home
About Us
Caregivers
Staff
Board of Directors
Partnerships & Sponsors
Training
History
FAQs
Services
In-Home Care
Equipment Loan
Health Navigation
News & Events
Who We Help
Support Us
Donate Now
Monthly Donations
Planned Giving
Get Involved
Donate Time
Donate Equipment
Become a Caregiver
Volunteer Stories
Contact Us
Volunteer Caregiver Application
Date of Application
Full Name
Address with ZIP code
Mobile Phone
Alternative Phone
Email
Date of Birth
Gender
Female
Male
Other
Bilingual (assumes English)
Spanish
Other
Ethnicity
Caucasian
Hispanic
Native American
African American
Asian
Other
Smoker
Yes
No
Do you have any qualifications in health-related fields (Doctor, RN, CNA, other?)
Do you have any experience in health-related fields including caregiving? Please describe.
What, if any, volunteer experience do you have?
Which of the following volunteer services are you interested in providing through Coming Home Connection? Please check all that are applicable.
Hospice
Assistance in the home to seniors or others with temporary or permanent disabilities
Working with seriously ill children
Medical equipment loan program
Office help, website/computer skills, fundraising
Other
If you are interested in offering caregiving services, please check any or all of the following services you feel qualified to provide (training will be provided as needed):
Companionship
Errands
Grocery Shopping
Meal Prep
Light housework
Laundry
Driving to Appointments
Dementia Care
What skills or personal interests do you have that may assist you in supporting caregiving clients?
What personal qualities do you bring to the CHC caregiving experience?
What do you hope to gain from your experience as a CHC volunteer?
Do you have any health issues that may limit your service as a caregiver?
Brief work history. You are invited (not required) to attach a resume.
Please provide two references: name, relationship and phone number for each.
Emergency contact: name, relationship and phone number
I agree to CHC checking my references and obtaining a background check.
Yes
No
Please provide any additional information that will help us understand how you may best fit with CHC clients and programs. Thank you for your interest in volunteering with Coming Home Connection!
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