Volunteer Month Year
Email (required to submit form):
Turn in by the 1 st of each month.
Please track your mileage and indicate if you want to be reimbursed.
Please sign at the bottom.
Please report time as follows:
0 – 15 min. = .25 hours 15 – 30 min. = .50 hours 30 – 45 min. = .75 hrs. 45 – 60 min. = 1.00 hr.
Date
Mileage
Notes/ Comments
Admin./ Office
Bereavement
Education/ Conference
Fundraising
Other
Please Select 0-15 min 15-30 min 30-45min 45-60 min 60-75 min 75-90 min 90-105 min 105-120 min
Please Select 0-15 min 15-30 min 30-45min 45-60 min 60-75 min 75-90 min 90-105 min 105-120 min 120-135 min 135-150 min 150-165 min 165-190 min
Please Select0-15 min 15-30 min 30-45min 45-60 min 60-75 min 75-90 min 90-105 min 105-120 min 120-135 min 135-150 min 150-165 min 165-190 min
Please Select0-15 min 15-30 min 30-45min 45-60 min 60-75 min 75-90 min 90-105 min 105-120 min
Total Mileage No Charge Please Reimburse
Volunteer Signature Date type your name to electronically sign this form
©2010 Redmond Sisters Hospice Privacy Policy