Date

Name

Address

City

State

ZIP code

Home Phone Number

Mobile Phone Number

Email Address

Comfortable with technology? Comfortable with technology? YES, I am comfortable with computer technology

Age Range Age RangeAge 18-29Age 30-49Age 50-69Age 70+

What interests you about volunteering for End of Life Choices California?

What kind of time commitment would you like to make?

Have you recently experienced the death of a friend or family member? If so, when?

Are you affiliated with other end-of-life organizations? Are you affiliated with other end-of-life organizations? Yes No

Please list your other end-of-life organization affiliations

Describe the skills and experience you would like to bring to End of Life Choices California

Skills and Interests Skills and Interests Data Entry & Office Support Writing or Editing projects In-person support of terminally ill clients Phone support of terminally ill clients Social Media Participation

Add'l Skills and Interests Add'l Skills and Interests Hosting or planning an event Public Speaking Hosting an education table at a Fair or Convention Distributing brochures or magazines Fundraising

Languages you speak fluently?

Professional experience, volunteering experience and/or degrees:

Would you like to introduce End of Life Choices California to any professional, religious, cultural, or social organizations to which you belong? Would you like to introduce End of Life Choices California to any professional, religious, cultural, or social organizations to which you belong? No Yes

Please list organizations you'd like to introduce us to

Number