Personnel & Emergency Contact Record

Any changes in address, phone numbers and emergency contact information needs to be communicated to the Director of Volunteer Services as soon as possible. A request will be made at least annually to update information.

Year

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Emergency Contact Name

Emergency Contact Phone

(###)

###

####

Electronic Signature

Typing your name serves as a written signature

Date

YYYY

BY CLICKING YES YOU ATTEST THAT YOU HAVE READ: Emergency Preparedness for Volunteers – In the event of an emergency, HONC staff will NOT have any roles assigned or responsibilities as part of volunteering for HONC. In the event that a HONC staff member requests support during a declared emergency, volunteers are to decline. If a volunteer is in a patient’s home, a facility, and/or in the Hospice office at the time of declared emergency, the volunteer will be instructed by emergency personnel or HONC essential personnel how and when to evacuate/leave premises, as appropriate or necessary.

Personnel & Emergency Contact Record

Listen. Comfort. Serve.

Plattsburgh Office

Malone Office

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