Bruce Peninsula East Grey & Area Owen Sound & Area Saugeen Central Shoreline

Volunteer Application Form1350 16th St. East. Owen Sound, ON

Ph: 519 371-3108 Fax: 519 372-2748

Contact InformationName (Mr. Mrs. Ms.)

Street Address, P.O. Box#

City & Postal Code (Fire #)

Home Phone

Work / Cell Phone

E-Mail Address

Persons to Notify in Case of Emergency

Name Phone Relationship

Please indicate your area(s) of Interest Transportation Driver Friendly Visiting Meals on Wheels Delivery Board of Directors Day Away Program Virtual Volunteering (Computer) Day Away Driver Newsletter / Communications Day Away Entertainment Fundraising / Events

Availability & Preference

What day(s) of the week would you be available? Monday Tuesday Wednesday Thursday Friday Saturday Sunday

What Months of the year are you available? January February March April May June July August September October November December

How much time are you able to spend volunteering? Weekly Bi-weekly Monthly Other considerations regarding availability

Are you volunteering for a specific community group? No Yes

Name or Organization:Name of Contact: Phone:Email:

(The following questions, which are personal in nature, are asked to assist us in matching you with a compatible volunteer experience. Please feel free to leave blanks.)

Page 1 of 2 Form: VM-1aReviewed: Aug. 2014

Bruce Peninsula East Grey & Area Owen Sound & Area Saugeen Central Shoreline

Volunteer Application Form1350 16th St. East. Owen Sound, ON

Ph: 519 371-3108 Fax: 519 372-2748

Are you affected by any special health restrictions which limit the kind of volunteer work that you may perform?

No____ Yes (please describe):___________________________________________________

Are you a smoker? No____ Yes____ Date of Birth:___________________________________

Interests, Hobbies & Background (Employment – Volunteer)

ReferencesPlease list three people who have knowledge of your qualifications. References should have known you for a minimum of two years. Must not be immediate family. Name Relationship Phone Number Length of time

known

How did you hear about volunteer opportunities for Home & Community Support Services? Newspaper Radio Internet Word of Mouth Poster Other

I give my permission for the references above to be contacted in connection with my application for a volunteer position with Home & Community Support Services.

I understand that the screening process of Home and Community Support Services of Grey-Bruce includes an application form, an interview and reference checks. Upon receipt of a conditional offer of a position I understand that some positions may also require additional checks such as driving licenses, insurance confirmation and police checks.

Signature of Volunteer_____________________________________Date:________________________________

Page 2 of 2 Form: VM-1aReviewed: Aug. 2014