All fields are required. If a question does not apply to you, please enter NA.

    Referral Source
    Friends WebsiteFriends Flyer or BrochureFriends Community EventRadioNewspaperFriend/RelativeFacebook/Other Social MediaI am a Friend/Relative of a Hospice PatientOther

    Friends Community Event

    Name of Friend/Relative

    Name of Friend/Relative who is a Hospice Patient

    Your name
    First:
    Middle:
    Last:
    Address Street:

    City:
    Zip:
    County:
    Contact Information

    Email

    Preferred Phone -
    ( ) -
    Secondary Phone -
    ( ) -
    Seasonal Information

    Do you reside outside of Florida during the year

    Months you reside in Florida
    JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberAll Year

    Seasonal Address
    Street:

    City:
    State:
    Zip:

    Seasonal Phone

    ( ) -

    Emergency Information
    Emergency Contact Name
    Emergency Contact Phone
    ( ) -
    Languages/Education

    Languages other than English

    Student
    Education/Grade
    Employment
    Retired
    Occupation/Former Occupation:

    Employment Status
    Employer Name

    Are you a Veteran?
    If yes, Branch:
    References

    List 3 personal references other than family members:


    Reference 1

    Name:
    Phone
    ( ) -
    Street (optional):
    City (optional):
    State (optional):
    Zip (optional):

    Reference 2

    Name:
    Phone
    ( ) -
    Street (optional):
    City (optional):
    State (optional):
    Zip (optional):

    Reference 3

    Name:
    Phone
    ( ) -
    Street (optional):
    City (optional):
    State (optional):
    Zip (optional):
    Skills/Limitations

    Please check your skills and abilities

    ClericalComputerCraftsFund RaisingMassagePublic SpeakingTeachingOther


    Limitations
    If yes, please explain:

    Interests

    Please select the Friends activities you are interested in

    Administrative SupportBulk MailCommunity EventsCourierFund RaisingGrief SupportChildren/Teens CampThrift Shoppe
    Availability

    Days Availabile

    SundayMondayTuesdayWednesdayThursdayFridaySaturday

    Times Available

    Personal
    Date of Birth
      
    Are you fearful of pets?
    Do you smoke?

    Club/Organization Memberships
    Religious Affiliation

    Have you experienced the death of someone close to you within the last year?
    If yes, please explain:


    Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses, which has not been annulled, expunged or sealed by the court?
    If yes, describe:

    Verification and Submission

    I hereby certify that the above information is true and complete to the best of my knowledge. I give permission for Friends of Citrus and the Nature Coast to contact any reference provided. I understand that misstatement or omission of fact may result in my dismissal.

    By initialing here , I confirm that I have read the above statement and agree that it is true.

    Notice: If applicant is under the age of 18, a parent or guardian must co-sign application at meeting with Volunteer Services Manager.

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