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Your First Name
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*
Relative
Friend
Self
Other
Patient's First Name
*
Patient's Last Name
*
Most Serious Illness
*
Patient's Insurance Plan
Patient's Physician's Name
Brief Question or Concern
*
Request help for community grief support from Hospice & Palliative Care Buffalo
First Name
*
Last Name
*
Email
*
Daytime Phone
*
Brief Question or Concern
*
Refer your patient to Hospice & Palliative Care Buffalo
Your Name
*
Name of Medical Office you Represent
Phone Number
*
Patient's First Name
*
Patient's Last Name
*
Patient's Insurance Plan
Patient's Estimated Prognosis
*
6 months or less
More than 6 months
Patient's Diagnosis
*
Brief Question or Concern
*
Essential Care for Children
Your Name
*
Your Phone Number
*
Your Email
Preferred Method of Contact
*
Phone
Email
Relationship
*
My Relative
My Friend
Other
Patient's Name
*
Most Serious Illness
*
Patient's Insurance Plan
Patient's Physician's Name
Brief Question or Concern
*
Become a Volunteer at Hospice & Palliative Care Buffalo
Name
*
Street Address
*
City, State
*
Zip Code
*
Email Address
*
Telephone: Home
Telephone: Cell
Telephone: Work
Can you receive calls at work?
Yes
No
Current Place of Employment & Position
*
Date of Birth
*
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*
Relationship
*
Emergency Contact Phone
*
Emergency Contact Address
*
How did you find out about Hospice Volunteering?
*
Utilized services in the past
Newspaper/TV/Radio ad
Social Media
Website
Word of Mouth
School/Organization Volunteer Hours
School
Grade
School Contact
School Contact Phone
Parent/Guardian
Parent/Guardian Phone
Most schools require a certain amount of volunteer hours for specific courses or graduation. Will you be fulfilling these hours through volunteering with Hospice?
Yes
No
If yes, how many hours do you need?
Do you plan on volunteering after you've completed your hours?
Yes
No
Military Experience: Branch
Dates of military service
Interest and/or Certification
Computer
Home Repairs
Notary
Sewing
Cooking/Baking
House Cleaning
Reading aloud
Yardwork
Hairstylist
Musician
Registered Nurse
Videography/Audio
Are you fluent in a foreign language or American Sign Language?
Other: Please Explain
Time Availability *
*
Weekday Mornings (7am-12pm)
Weekday Afternoons (12pm-5pm)
Weekday Evenings (5pm-9pm)
Weekday Overnight (9pm-7am)
Weekend Mornings (7am-12pm)
Weekend Afternoons (12pm-5pm)
Weekend Evenings (5pm-9pm)
Weekend Overnight (9pm-7am)
Desired Areas of Volunteering
*
Special Events
Administrative
Patient Support/Direct Care
Administrative Services (M-F daytime positions)
Phone receptionist
Greeting campus visitors
Cafe
Baking
Filing
Nurses' station receptionist
Mailings
Gardening
Direct Care/Patient Support
Visit patients in their homes (hospice & pre-hospice)
Visit patients in the inpatient unit (Cheektowaga)
Visit patients in a facility (nursing home/ assisted living /hospital/group home)
Visit bereaved families
Hairdresser (copy of current license required if providing services to patients)
Pet therapy
Phone support
Delivering birthday cakes to patients
Audio recording of patients' stories
Patient/caregiver transportation
Evening & weekend refreshment cart (inpatient unit in Cheektowaga)
Veterans helping veterans
Children's programs
Special Events
Yes
No
Have you experienced the loss of a loved one in the past year? If so, please briefly describe:
Have you been convicted of a crime? *
Yes
No
If yes, please explain:
References
Two references are required of Hospice & Palliative Care Buffalo volunteers. Please note, referances should be professional in nature. Members of your family will not be considered as references regardless of any professional relationship with them. References from work or volunteer assignments are most helpful. Please use full names & provide complete addresses.
Name (1st reference)
*
Street Address
*
City/State
*
Zip
*
Email Address
Phone
*
Position/Relationship to you
*
Name (2nd reference)
*
Street Address
*
City/State
*
Zip Code
*
Email Address
Phone
*
Position/Relationship to you
*
I hereby authorize Hospice & Palliative Buffalo to request of the above individuals' information regarding my appropriateness as a Center for Hospice & Palliative Care volunteer.
*
Sign electronically with your full name.
I grant full permission to Hospice & Palliative Care Buffalo and its affiliates to use photographs of me for print and/or digital promotional purposes.
*
Sign electronically with your full name.
Send a general question to Hospice & Palliative Care Buffalo
Name
*
Address
Email Address
*
Phone
Brief Question or Concern
*
Update your address with Hospice & Palliative Care Buffalo
First Name
*
Last Name
*
Email Address
*
Phone Number
Address
*
City
*
State
*
Zip Code
*
I Would Like To:
*
Update my mailing address
Receive email communication
Communication via mail
Unsubscribe to emails
Unsubscribe to mailing list
Unsubscribe to both emails and mailing list
Brief Question or Concern
*
Have you been touched by Hospice Buffalo's exceptional care or moved by one of our special services or staff?
We'd love to hear your story and possibly share it with others.
Patient's Name
Your First Name
*
Phone Number
*
My Story
*
Do you have a photo that you would like us to use with your story? Click to upload your jpeg file.
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:
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Questions or Concerns
Submit a speaker request to Hospice & Palliative Care Buffalo
Name
*
Email
*
Phone
*
Organization/School Name
*
Address
*
Anticipated Dates
*
Type of Speaker
*
Research Education
Informational
Desired Topic
*
Brief Question or Concern
*
Photo Release Form
Name of Person in Photo/Audio/Video
*
Please select
*
Patient
Community
Staff
Address
*
Phone
*
Please select
*
Cell
Home
Work
Email
*
Please complete this section if primary caregiver providing authorization signature below
Name
*
Relationship to patient
*
Address
Phone
*
Please select
*
Cell
Home
Work
Email
*
Please Sign
Electronic Signature
*
Date
*
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
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5
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19
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25
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27
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29
30
31
Year
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
Internal Use ONLY
Event/Occasion
Name of Hospice Staff obtaining authorization
Title
Department
Request help for a loved one or myself from Hospice & Palliative Care Buffalo
Your First Name
*
Your Last Name
*
Your Phone Number
*
Email
Relationship
*
Relative
Friend
Self
Other
Patient's First Name
*
Patient's Last Name
*
Most Serious Illness
*
Patient's Insurance Plan
Patient's Physician's Name
Brief Question or Concern
*