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Volunteer Activity Report
Volunteer First Name:
*
Volunteer Last Name:
*
Site:
<Select>
Barbourville
Cynthiana
Frankfort
Hazard
Lexington
Lexington Inpatient Units
Northern Kentucky
Pikeville
*
Volunteer Service Provided:
<Select>
11th Hour
Beautician/Barber
Bereavement Support
Companionship (Home)
Companionship (InPatient)
Companionship (Nursing Home)
Cooking/Cleaning in a Patient Home
Fundraising
Gardening/Yardwork
Handyman
Health Fairs
Manicure/Pedicure
Massage
Office/Admin
Palliative Companionship
Palliative Respite
Pet Therapy
Provide Meals
Reiki
Respite (Home)
Respite (InPatient)
Respite (Nursing Home)
Sewing
Shopping/Errands
Special Events
Student
Transportation
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*
Enter your own value
*
Date of Service:
*
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Enter the date that you performed this volunteer activity in the format mm/dd/yyyy.
Hours (for patient care, this should include your time traveling to and from the appointment):
*
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Enter Hours:Minutes e.g. If you were there for one hour and 40 minutes you would enter 1:40. PLEASE INCLUDE YOUR TRAVEL TIME TO AND FROM THE APPOINTMENT.
Patient Name:
*
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If your service was with a patient, please enter the patient's name or Patient ID.
Additional Comments:
*
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Maximum 500 characters