Volunteers Volunteer Activity Note Submission Form Office(Required)Olathe, KSWichita, KSIndependence, MOSpringfield, MOArdmore, OKGrove, OKOklahoma City, OKTulsa, OKDallas, TXHouston, TXSan Antonio, TXVolunteer InformationFirst Name(Required) Last Name(Required) Email(Required) Activity(Required) Home Visit Nursing Home Visit Administrative Assistance Special Service Phone Call Training / Inservice Other Patient InformationPatient Name(Required) Medical Record Number(Required) Activity or Support Provided(Please check all that apply.)Patient/Family Support Socialized with patient Read to patient Sat quietly with patient Performed tasks for patient Took meal/treat/specialty item Took patient out of room per volunteer training guidelines Assisted with special activity (see additional information for detail) Visited with patient's family Offered companionship/relief for caregiver Provided support at time of death Attended funeral service Other OtherAdministrative Assistance Assisted office staff Assisted with family support program Other OtherAdditional InformationActivity Start Time Hours : Minutes AM PM AM/PM Activity End Time Hours : Minutes AM PM AM/PM Mileage Travel Time Date MM slash DD slash YYYY RemindersIf you have a question, concern, or need that you feel needs to be addressed, please contact the hospice office as soon as possible. Your calls are always welcome. We appreciate you and are always available to you for support and assistance. IN CASE OF EMERGENCY, CONTACT THE HOSPICE OFFICE IMMEDIATELYCAPTCHA
