Volunteer Service Activity Form *Required Field Visit Date* Volunteer Name:* Office name:* Select One GEORGIA — Athens, Georgia Atlanta, Georgia Augusta, Georgia Blue Ridge, Georgia Buford, Georgia Calhoun, Georgia Cobb, Georgia Cordele, Georgia Gainesville, Georgia Macon, Georgia Newnan, Georgia Peachtree Christian Hospice, Georgia Rome, Georgia Savannah, Georgia Swainsboro, Georgia Union City, Georgia Valdosta, Georgia NORTH CAROLINA — Coastal Carolina, New Bern East Carolina, Farmville East Carolina, Raleigh/Durham East Carolina, Rocky Mount East Carolina, Smithfield Fayetteville, North Carolina Wilkes, North Carolina SOUTH CAROLINA — Aiken, South Carolina Anderson, South Carolina Beaufort, South Carolina Charleston, South Carolina Chester, South Carolina Columbia, South Carolina Orangeburg, South Carolina Pee Dee, South Carolina Simpsonville, South Carolina Patient Initials* Patient I.D.* Time In (am:pm)* Length of visit* Total travel time* total mileage* 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. Submit Using the Submit button constitutes an electronic signature.