Volunteer Service Activity Form

*Required Field

Visit Date is required

Volunteer Name is required

OFFICE NAME:*

Area is required

Patient Initials is requried

Patient I.D. is required

Time In is required

Length of visit is required

Total Travel time is required

Total mileage is required

TYPE OF SERVICE:*

Select One

Respite

Sit with patient for short periods of time while caregiver goes to church, shopping, appointments, etc.

Companionship

​Read aloud, write letters, life review, play cards, play games or music, organize photo albums or papers, watch TV or movies, bird watch, take dictation, puzzles, crafts, etc.

Emotional

Support Grief support.

Other:

If other please describe type of services needed

DESCRIBE WHAT OCCURRED DURING VISIT WITH PATIENT:*

Please ensure information is accurate.

Visit activity description is required