Los Angeles Jewish Home

Skirball Volunteer Form

If you have a passion for providing a higher quality of life for the Los Angeles Jewish Home residents, we have a myriad of ways for you to share your time and your talents to enhance the well-being of our seniors. please fill out the form below and someone from our Volunteer Department will contact you.

For a printable version of this form, please click here.

Items in bold are required.

Contact Information

First Name:

Middle Name:

Last Name:

Address:

City:

State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusettes Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesse Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

E-mail Address:

Home Phone #:

Work Phone #:

Cell Phone #:

Experience

Employer:

Occupation:

Working Hours:

Briefly describe the type of work you do:


Total number of hours per week you could be available for hospice volunteering:

Daytime:	Evenings:	Weekends:	Other:
Education Level:
High School	2 Year College	4 Year College	Post Grad

Foreign languages spoken:

Religious Affiliation: (Optional—this assists us in proper placement of our volunteers. We serve patients regardless of religious affiliation).
Catholic	Protestant	Jewish	Other

Personal Information:

How did you hear about us?


Why do you wish to be involved in hospice?


What organizations or clubs do you belong to?


Have you had experience with the terminally ill?

Yes   No

(If yes, please explain)


Has someone close to you died within the past year?

Yes   No 

(If yes, please note who)


What do you like about yourself?


Do you have available transportation for your volunteer work?

Yes   No

Do you have a valid California driver’s license?

Yes   No

Do you have automobile liability insurance?
(Auto insurance is required if you use your car for hospice work)

Yes   No

Have you been convicted of a felony within the last 7 years? (Conviction will not necessarily disqualify you from volunteering.)

Yes   No

List experiences you believe would be helpful to you in hospice volunteering, i.e., schooling, work, volunteer experience, office skills, arts and crafts, etc.

Areas of Interest:

(please check areas of interest)

Direct:

Patient and/or family visits	Meal preparation	Shopping/run errands
Relieve primary caregiver	Read to patient	Homemaking chores
Transportation	Write letters	Child care
Bereavement follow-up

Indirect:

Speakers bureau	Sewing/crafts	Computer work
Office assistance	Videotaping	Music or entertaining
Host/hostess for hospice events	Photography	Mass mailings

Third Parties

Personal References: (with phone numbers) Please list two.

In Case of Emergency:

Name:

Relationship:

Home Phone #:

Work Phone #:

Physician:

Office Phone #: