Volunteer Caregiver Application

Date of Application

Full Name

Address with ZIP code

Mobile Phone

Alternative Phone

Date of Birth

Gender

Female Male Other

Bilingual (assumes English)

Spanish 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):

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!

418 Cerrillos Rd #23

Santa Fe, NM 87501

(Shops at the Design Center in Santa Fe)

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Coming Home Connection puts out a newsletter approximately quarterly. This newsletter is available to anyone who is interested in the details of our work.