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Volunteer Application Form

Thank you for your interest. This information is needed by Hospice Mid-Northland to assist in your placement in the volunteer team in case of emergency and for our statistical purposes. After completing and submitting this form our Manager of Volunteers Services will be in contact with you to discuss and progress your application.

Post Code*
Email Address*
Date of Birth*
Home Phone*
Mobile Number
What is your previous work experience?
Are there other interests and skills you could bring to the hospice?
What motivated you to volunteer for Hospice?
Name of your GP to contact in case of emergency*
1st Contact person in case of emergency*
Relationship with 1st Contact person*
Phone 1st Contact person*
2nd Contact person in case of emergency*
Relationship with 2nd Contact person*
Phone 2nd Contact person*
Please list any medical conditions and/or limitations that might affect your work ...
Please tick the area(s) that you are prepared to work in as a volunteer*
Would you allow us to include you in a text list to communicate with you when we are short of Volunteers?*
Volunteer Roles ... What type of work would you like to do for the hospice?*


Hospice mid-northland
Address - 464 Kerikeri Road, Kerikeri
Postal - PO Box 141, Kerikeri 0245
(Please use our PO Box if you intend on sending mail)
Phone 09 407 7799 - email
© Hospice mid-northland - All rights reserved
Charities Commission Registration Number CC1024
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