Volunteer Application

For privacy reasons, please do not include personal information containing diagnoses and/or treatments.

Volunteer Application

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CONTACT INFORMATION

Name

First Middle Last

Phone

Email

Address

Street Address Town / City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code

Are you 15 years of age or younger

Yes

No

Please tell us your age

Parent / Guardian Awareness: You will receive a printable PDF copy of this application via the email address specified. Please print this document and obtain the required guardian / parent signature.

EDUCATION

Not required to be a volunteer – we welcome experience of all kinds.

Are you currently a student?

Yes

No

School Name

Grade Level / Year of Study

Course of Study

Expected Date of Graduation (dd-mm-yyyy)

DD dash MM dash YYYY

Are you receiving credit for your volunteer work?

Yes

No

# of hours

By when? (dd-mm-yyyy)

DD dash MM dash YYYY

What is your highest level of education?

(please choose)High SchoolTrade / BusinessUniversity / CollegeOther

Degree / course of study

(please specify)

Other education level

(please specify)

EMPLOYMENT & VOLUNTEER HISTORY

Currently, I am…

(please choose)EmployedHomemakerRetiredStudentUnemployed

Company Name / Employer

(current or last)

Job title

(current or last)

Employed from (dd-mm-yyyy)

DD dash MM dash YYYY

Employed to (dd-mm-yyyy)

DD dash MM dash YYYY

Reason(s) for leaving

Volunteer Work

Organization

Time Period

Responsibilities

Reason(s) for leaving

 

Add Remove

List organizations in your community that you are involved with (incl. Community clubs, schools, religious organizations, professional associations, non-profit organizations, sporting organizations, etc.)

Have you ever volunteered with this organization before?

Yes

No

When were you a volunteer? (dd-mm-yyyy)

DD dash MM dash YYYY

Select the site where you want to volunteer

(please choose)Altona Community Memorial Health CentreBethesda PlaceBethesda Regional Health CentreBoundary Trails Health CentreBoyne Lodge Personal Care HomeCarman Memorial HospitalCentre de santé – Foyer Notre DameCentre de santé Notre Dame Health CentreCentre de santé St. Claude Health CentreCentre médico-social De Salaberry District Health CentreDouglas Campbell LodgeEastview PlaceEden Mental Health CentreEmerson Health CentreGladstone Health CentreHeritage Life Personal Care HomeHôpital Ste-Anne HospitalLions Prairie ManorLorne Memorial HospitalMacGregor Health CentreMenno Home for the AgedMorris General HospitalPembina Manitou Health CentrePortage District General HospitalPrairie View LodgeRed River Valley LodgeRepos JolysRest Haven Nursing HomeRock Lake Health District HospitalRock Lake Health District Personal Care HomeSalem Home Inc.Tabor Home Inc.Third Crossing ManorVilla Youville Inc.Vita & District Health CentreVita & District Personal Care Home

What skills and experience you have to offer?

(check all that apply)

Class 5 driver’s license

Clerical, organizational

Computer, technology

Experience with children/youth

Experience with elderly

Facilitation

Food handling / service

Fundraising experience

Health care

Languages

Public speaking

Recreation / coaching

Research

Training / education

Writing

Other

Other skills

(please specify)

What are your reason(s) for volunteering?

(check all that apply)

Academic credit

Employment experience

Explore careers

Increase self-esteem

Learn new skills

Help others

Improve health care

Social interaction

Relative / friend volunteers

Practice English skills

Stay active / involved

Other

Other reasons

(please specify)

How did you find out about our volunteer program?

Community

Employee of SH-SS

Info booth

Newspaper

Physician

Poster / brochure / flyer

Previously a patient / client

Previously a volunteer

Radio

Relative / friend

School

Volunteer

Website / Social Media

Other

(check all that apply)

Other source

(please specify)

AVAILABILITY

Select preferred time periods you are available to volunteer for the next three months. Specify times you would arrive/leave your shift.

Day(s) of the week

(choose all that apply)

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Time of Day

(choose all that apply)

Morning

Afternoon

Evening

Arrival Time

Hours

:

Minutes

AM PM AM/PM

Departure Time

Hours

:

Minutes

AM PM AM/PM

How many shifts a week would you like to volunteer?

Are there times of the year that you are not available to volunteer?

Are you interested in volunteering for special projects or events?

Yes

No

Health Information

Please list any intellectual or physical disabilities or health problems which may affect your ability to perform as a volunteer and that you wish to have taken into considerations when determining a volunteer placement.

e-Signature

Parent / Guardian Awareness: You will receive a printable PDF copy of this application via the email address specified. Please print this document and obtain the required guardian / parent signature.

After clicking on the ‘Submit’ button, you will see a page confirming that your submission has been received.