VOLUNTEER APPLICATION FORM - Victoria General Hospital

VOLUNTEER APPLICATION FORM
Victoria General Hospital
2340 Pembina Hwy. Winnipeg, Manitoba R3T 2E8
Phone: (204) 477-3347 Fax: (204) 477-3271
Email: volunteer@vgh.mb.ca
All information on this Volunteer Application Form, whether submitted online or in paper directly to
Victoria General Hospital Volunteer Services, will be entered to a website owned by Volgistics, Inc. and
not Victoria General Hospital or the Winnipeg Regional Health Authority (WRHA).
Volgistics is a third party contracted to manage and store all information on volunteers collected by
Victoria General Hospital, including, but not limited to: this application, personal information, volunteer
assignments, service hours, awards, etc. Volgistics currently stores this information on servers located
outside of Canada so this information will be subject to the laws of the country where it is kept. Victoria
General Hospital and the WRHA are not responsible for any lost or misdirected data or for any delays
while data is being sent to or stored on the Volgistics website. Information about Volgistics’ Security
Features, Privacy Policies and Terms of Use can be found on its website at www.volgistics.com.
PLEASE TELL US ABOUT YOURSELF:
ڤ
Mr. ڤ Ms. ڤ Mrs. Last Name:
First Name:
Middle Name:
Address:
City:
Province: Postal Code: E-Mail:
Phone: Home
Business
Cell
PLEASE TELL US ABOUT YOUR EDUCATION:
Formal education is not required to be a volunteer. We welcome experience of all kinds!
Name of School
Highest level
obtained
Currently attending
Yes/No
Junior High
High School
Post Secondary -
College/University
Other
07/09/12

PLEASE TELL US ABOUT YOUR EMPLOYMENT HISTORY:
ڤ
Employed ڤ Unemployed ڤ Retired ڤ Student ڤ Homemaker Company Name/Employer Your Job From To Reason for Leaving
PLEASE TELL US ABOUT THE VOLUNTEER WORK YOU HAVE DONE:
Organization Your Title/Placement From To Reason for Leaving
Have you ever applied to volunteer with this organization before? ڤ Yes ڤ No
If yes, When?
PLEASE CHECK (√) WHICH AREA YOU ARE INTERESTED IN:
ڤ
Patient Care Programs ڤ Non Patient Care Programs ڤ
Junior Volunteer Program (16-17 years of age) PLEASE INDICATE THE EXACT TIME (i.e. 9 –11am) YOU ARE AVAILABLE TO
VOLUNTEER.
Morning
Afternoon
Evening
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
07/09/12

TIME COMMITMENT
I am willing to make a commitment of a minimum of 3 months ڤ YES ڤ NO
Please note the times of the year you are not available to volunteer (i.e. vacation)
WHO WOULD YOU LIKE US TO CONTACT IN CASE OF AN EMERGENCY?
Name:
Phone: Home Work Cellular
OPTIONAL
If you wish to have anything further to be taken into consideration when determining a volunteer
placement (for example: mobility issues, back problems or allergies) you may list those issues in
the space provided.
References, Photo Consent and Disclaimer
If you are interviewed as a potential volunteer, you will be asked to provide three (3) references.
Please note references from family members or from personal friends will not be accepted,
unless you were employed by them.
I hereby give the Victoria General Hospital and the Guild of Victoria General Hospital the
absolute right and permission to copyright and/or publicize, or use photographic portraits or
pictures of me, or videotaped images in which I may be included in whole or part for the use of
advertising, art, trade and any other lawful purpose whatsoever.
By submitting this application, I agree that the information I have provided on the form is true
and accurate. Furthermore, I understand and agree that submitting this application form does
not automatically register me as a volunteer. It is the policy of Victoria General Hospital
Volunteer Services to screen all prospective volunteers. While we try to place every prospective
volunteer, management reserves the right to decline applicants who do not meet our
requirements and/or placement criteria. I consent to this information and information about my
volunteer work with Victoria General Hospital to be maintained on the Volgistics website and
absolve and release Victoria General Hospital from all and any liability that may otherwise
accrue by reason of keeping this information on the Volgistics website and using this
information for Victoria General Hospital purposes.
Signature: __________________________________
Date: ____________________
07/09/12