Application for Volunteer Service
Contact Information
Last Name:
First Name:
Mr.
Ms.
Mrs.
Miss
Address:
Postal Code:
Phone:
Business:
Email:
I prefer to receive calls at
Home
Business
Best Time:
Age:
14-17
18-25
26-34
35-45
46-55
56-70
70+
Note: A Guardian Awareness Form must be completed by applicants 17 years or younger.
Please contact Volunteer Services at Concordia Hospital if you require one.
Employment History
Company Name/Employer
Your Job Title
From
To
Reason for Leaving
Your Volunteer Work
Organization
Your Placement
From
To
Reason for Leaving
Have you ever applied to volunteer with this organization before?
Yes
No
If yes, when?
Education
Formal education is not required to be a volunteer. We welcome experience of all kinds.
Name of School
Course of Study
Start and End Dates
High School:
Post Secondary College/University
Professional Training
i.e. Nursing/Physiotherapist
Trade or Business
Availability
please specify the time you would arrive and leave Concordia to volunteer for your shift.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Morning:
Afternoon:
Evening:
Time Commitment:
minimum 3 months
other
How many times per week would you like to volunteer?
Please check which of the following assignments are of interest to you.
Clerical Assistance
Emergency*
Gift Shop*
Lab/Histology/X-ray
Volunteer Ambassador*
Spiritual Care
Recreation Activities*
Education Services
Palliative Care Visitor*
Escort Services
Special Events
Oncology
Volunteer Services
Gardening Assistant
Food Services/Vending*
Friendly Visiting*
Foundation Projects
Please note: We have limited opportunities during the evenings and on weekends. Positions marked with an asterisk (*) indicate availability on evenings and weekends.
Please check skills and experiences you have to offer
Cash Handling Experience
Fundraising
Computer Skills
Musical Ability
Creative Ideas
Photography
Organizational Skills
Special training (specify)
Languages (Specify)
Nursing
Entertainment Contact
Retail Experience
Physical Strengths
Other (Specify)
Communication
Experience with the Elderly
Please check main reason for volunteering
Academic Credit
Help others
Practice English skills
Employment Experience
Improve health care
Referred by medical professional
Explore careers
Social interaction
Stay active & involved
Increase self-esteem
Relative/friend volunteers
Other (Specify)
Learn new skills
Mandated Community Service
Please check how you found out about our volunteer program?
Physician
School
Radio
Community
Newspaper
TV
Volunteer
Volunteer Center
Referral Organization (specify)
Previously a patient
Poster/brochure/flyer
Recruitment/Information Booth
Visited a patient
Knew about/noticed department
Relative/Friend
Employee of this organization
Human Resource Department
Website
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 haven taken into consideration when determining a job placement.
Have you had chicken pox?
Yes
No
Unsure
Who would you like us to contact in case of an emergency?
Name:
Relationship:
Phone (H):
Phone (W):
References
Please list three current references such as past/present employers, teachers/instructors, youth group leaders, colleagues or a supervisor from a volunteer experience. We do not accept family members or personal friends as references unless you were employed by them. We do accept signed reference letters that are current and on the organizations letterhead.
Name
Organization
How do you know
this person?
Phone No.
Fax No.
I hereby authorize Concordia Hospital Volunteer Services Department to solicit a reference from the above referees to ascertain my suitability as a volunteer. I also understand that untrue, misleading, or omitted information herein may result in dismissal, regardless of the time of discovery by Concordia Hospital. I hereby release Concordia Hospital from all liability for any damage whatsoever for issuing same I further authorize the Volunteer Department to maintain this information in their records and release and absolve them from all liability that may otherwise accrue by reason of their keeping this information and using it for their purpose.
Disclaimer:
We take our responsibility for patients and residents seriously, therefore, we screen all our applicants thoroughly. Information shared/learned through the screening process maybe shared with individuals who will be responsible for the performance of the applicant. While we try to place every prospective volunteer, management reserves the right to reject applicants.
