Date Application Was Received: Date Contacted:
Contacted By:
VOLUNTEER APPLICATION FORM
Applicant must be 16 years of age to apply
www.wrh.on.ca / Volunteer
Ouellette Campus: Renée Hopes, Manager of Volunteer Services and Student Registration
1030 Ouellette Avenue, Windsor, ON, N9A 1E1 Phone: (519) 254-5577 ext. 33184 Fax: (519) 255-2126
Metropolitan Campus: Olivia McGuire, Administrative Assistant
1995 Lens Avenue, Windsor, ON, N8W 1L9 Phone: (519) 254-5577 ext. 52343 Fax: (519) 985-2616
I would like to volunteer at the following campus: Metropolitan Cancer Centre Ouellette Any Campus
CONTACT INFORMATION:
(Please PRINT Clearly)
FIRST NAME MIDDLE NAME LAST NAME
STREET NAME & ADDRESS (APT. #/UNIT) CITY PROVINCE POSTAL CODE
HOME PHONE CELL PHONE EMAIL ADDRESS
(For Volunteer Services Office Use Only)
PERSONAL INFORMATION: (Please PRINT Clearly)
COVERED BY OHIP
DATE OF BIRTH AGE GROUP (Valid Ontario Health Card)
16 - 17 18 - 25 25+ Yes No
MONTH DAY CHECK THE APPROPRIATE BOX CHECK THE APPROPRIATE BOX
CITIZENSHIP STATUS: LANGUAGES SPOKEN:
Canadian Citizen English French Other (specify below)
Other Status (specify below):
_______________________________________ Other:__________________________________________
EMERGENCY CONTACT INFORMATION: (Please PRINT Clearly)
FIRST & LAST NAME HOME/CELL/WORK PHONE (CIRCLE) RELATIONSHIP TO YOU
YOUR APPLICATION WILL BE KEPT ON FILE FOR 6 - MONTHS
You will be contacted when your application has been received and reviewed.
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VOLUNTEER INFORMATION: (Please PRINT Clearly)
My goal for Volunteering at Windsor Regional Hospital is to:
Help Others Show Appreciation Learn New Skills Explore Career Opportunities Keep Active
Do you have access to an automobile for Volunteering:
Yes No Occasionally No – I use the City Bus
Length of commitment: 3 - 6 Months 6 - 12 Months Summer Only Assist with Special Events
I usually take extended vacations in the: Spring Season Summer Season Winter Season
Please indicate your area of interest below. Visit the website for more options regarding the various placement
areas/duties available in the hospital (i.e. Help Desk, Gift Shop, ER, Paediatrics, Outpatient Clinics)
First Choice: _____________________Second Choice:__________________Third Choice:____________________
Please indicate the TIME(S) that you are available in the boxes below i.e. Monday, 9:00 a.m. – 1:00 p.m.
Volunteer Assignments are 2-4 hour shifts, one - two days per week
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Morning
Afternoon
Evening
PHYSICIAL LIMITATIONS::Some Volunteer positions may require one to sit, stand or walk for extended periods
of time. Please let us know if you have any physical limitations we need to consider with respect to your desired
Volunteer Position.
No limitations Yes, I have some limitations and I have listed them below: (Please PRINT Clearly)
VOLUNTEER/COMMUNITY EXPERIENCE: (Please PRINT Clearly)
1. 1.
2. 2.
Organization Responsibilities How Long
EMPLOYMENT HISTORY:
Occupation (past or present):_______________________________________________________________________
Retired Employed Full-Time Looking for: Part-Time Full-Time Employment
Self Employed Employed Part-Time Currently not employed
EDUCATION BACKGROUND:
High School College/University: 1 2 3 4 (Please CIRCLE Year Completed) Not attending school
SKILLS/ INTERESTS/ HOBBIES::(Please CIRCLE all that best describe you)
Play Piano/Guitar/Sing Computer Skills (MS Word/Excel/Internet/Keyboarding) Crafts/Painting/Scrapbooking
Cards/Board Games Cooking/Baking Sewing/Knitting/Crocheting
Gardening Fundraising Events Public Relations
Teaching/Mentoring Social/Communication Skills/Friendly Visitor Golfing/Golf Tournaments
Nursing/PSW Background
Others (specify):___________________________________________________________________________________
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VOLUNTEER REFERENCE FORM - 1
Please provide two references. References cannot be provided from family members.
VOLUNTEER NAME: DATE:
REFEREES NAME: PHONE :
The above mentioned individual has applied to be a Volunteer at Windsor Regional Hospital and has given your
name as a reference.
Kindly complete the following questions and return this form to the Volunteer Applicant or you can submit
it directly to the following Staff Member noted below. All information will be held in confidence. Thank you
for completing this form.
1) What is your relationship with the applicant (i.e. employer, co-worker, teacher, doctor, pastor, etc.)?
2) How long have you known this person?
3) Do you feel the applicant would be a reliable, committed volunteer?
4) Does the applicant follow tasks through to completion?
5) What special qualities and/or strengths do you feel the applicant has which would make him/her a good
candidate for volunteering at the Hospital?
6) What areas do you feel the applicant needs to improve upon (i.e. punctuality, reliability, self-confidence, etc.)?
7) Would you recommend this person to volunteer for our organization? YES NO
Windsor Regional Hospital, Met/Ouellette Campus
Carolyn Brown, Administrative Assistant
Volunteer Services & Student Registration
1030 Ouellette Avenue
Windsor, ON N9A 1E1
Office: (519) 254-5577 ext. 33673
Fax: (519) 255-2126
[email protected]SIGNATURE: ________________________________________ DATE: _____________________
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VOLUNTEER REFERENCE FORM - 2
Please provide two references. References cannot be provided from family members.
VOLUNTEER NAME: DATE:
REFEREES NAME: PHONE :
The above mentioned individual has applied to be a Volunteer at Windsor Regional Hospital and has given your
name as a reference.
Kindly complete the following questions and return this form to the Volunteer Applicant or you can submit
it directly to the following Staff Member noted below. All information will be held in confidence. Thank you
for completing this form.
1) What is your relationship with the applicant (i.e. employer, co-worker, teacher, doctor, pastor, etc.)?
2) How long have you known this person?
3) Do you feel the applicant would be a reliable, committed volunteer?
4) Does the applicant follow tasks through to completion?
5) What special qualities and/or strengths do you feel the applicant has which would make him/her a good
candidate for volunteering at the Hospital?
6) What areas do you feel the applicant needs to improve upon (i.e. punctuality, reliability, self-confidence, etc.)?
7) Would you recommend this person to volunteer for our organization? YES NO
Windsor Regional Hospital, Met/Ouellette Campus
Carolyn Brown, Administrative Assistant
Volunteer Services & Student Registration
1030 Ouellette Avenue
Windsor, ON N9A 1E1
Office: (519) 254-5577 ext. 33673
Fax: (519) 255-2126
[email protected]SIGNATURE: ________________________________________ DATE: ______________________
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VOLUNTEER PLACEMENT AGREEMENT FORM
If accepted as a Windsor Regional Hospital Volunteer, I agree that:
1. I shall hold all confidential information that I may obtain directly or indirectly concerning clients,
staff, visitors, volunteers and students and not seek confidential information from any individual.
2. I will complete a pre-placement health screening which includes a 2-step tuberculosis test,
laboratory tests and/or provide documentation of required immunizations.
3. Due to hospitalization at WRH, our clients are considered vulnerable. I will complete an extended
criminal record check, which includes vulnerable sector screening and a check for pardoned
sexual offences. (Do not complete until an interview with a Volunteer Services Staff has
taken place).
4. I will report to my shift “in uniform” and follow the dress code with my WRH photo ID clearly visible.
5. My services are donated to the hospital without contemplation of compensation or future
employment.
6. I shall honour the duties and time commitment of the service assigned to, advising the Department
of Volunteer Services and Student Registration of any planned absences and any emergency
absences.
7. I will complete any/all orientation and training materials/sessions that are related to my Volunteer
Service Placement.
8. I understand that the Department of Volunteer Services and Student Registration reserves the right
to terminate my volunteer status at any time due to:
a. Failure to comply with hospital policies, rules and regulations
b. Problematic attendance
c. Negative and/or inappropriate comments or conduct
d. Any other circumstances which, in the judgment of the Department of Volunteer Services
and Student Registration makes my continued service as a Volunteer contrary to the best
interests of the Hospital and its clients.
9. I understand that it is my responsibility to read and abide by the policies, procedures, and
rules as stated in the Volunteer Orientation Materials, including but not limited to conduct and
ethical guidelines, dress code and safety. I will consult with the Department of Volunteer Services
and Student Registration regarding any orientation topic that I do not understand. In the event the
material is revised and/or otherwise updated, I will be informed and expected to abide by the most
current instructions.
I have read each of the above conditions and I agree to abide by them.
APPLICANT’S SIGNATURE: ___________________________ DATE: ___________________________
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