VOLUNTEER APPLICATION FORM - Victoria General Hospital
VOLUNTEER APPLICATION FORM - Victoria General Hospital
VOLUNTEER APPLICATION FORM - Victoria General Hospital
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<strong>VOLUNTEER</strong> <strong>APPLICATION</strong> <strong>FORM</strong><br />
<strong>Victoria</strong> <strong>General</strong> <strong>Hospital</strong><br />
2340 Pembina Hwy. Winnipeg, Manitoba R3T 2E8<br />
Phone: (204) 477-3347 Fax: (204) 477-3271<br />
Email: volunteer@vgh.mb.ca<br />
All information on this Volunteer Application Form, whether submitted online or in paper directly to<br />
<strong>Victoria</strong> <strong>General</strong> <strong>Hospital</strong> Volunteer Services, will be entered to a website owned by Volgistics, Inc. and<br />
not <strong>Victoria</strong> <strong>General</strong> <strong>Hospital</strong> or the Winnipeg Regional Health Authority (WRHA).<br />
Volgistics is a third party contracted to manage and store all information on volunteers collected by<br />
<strong>Victoria</strong> <strong>General</strong> <strong>Hospital</strong>, including, but not limited to: this application, personal information, volunteer<br />
assignments, service hours, awards, etc. Volgistics currently stores this information on servers located<br />
outside of Canada so this information will be subject to the laws of the country where it is kept. <strong>Victoria</strong><br />
<strong>General</strong> <strong>Hospital</strong> and the WRHA are not responsible for any lost or misdirected data or for any delays<br />
while data is being sent to or stored on the Volgistics website. Information about Volgistics’ Security<br />
Features, Privacy Policies and Terms of Use can be found on its website at www.volgistics.com.<br />
PLEASE TELL US ABOUT YOURSELF:<br />
ڤ<br />
Mr. ڤ Ms. ڤ Mrs. Last Name:<br />
First Name:<br />
Middle Name:<br />
Address:<br />
City:<br />
Province: Postal Code: E-Mail:<br />
Phone: Home<br />
Business<br />
Cell<br />
PLEASE TELL US ABOUT YOUR EDUCATION:<br />
Formal education is not required to be a volunteer. We welcome experience of all kinds!<br />
Name of School<br />
Highest level<br />
obtained<br />
Currently attending<br />
Yes/No<br />
Junior High<br />
High School<br />
Post Secondary -<br />
College/University<br />
Other<br />
07/09/12
PLEASE TELL US ABOUT YOUR EMPLOYMENT HISTORY:<br />
ڤ<br />
Employed ڤ Unemployed ڤ Retired ڤ Student ڤ Homemaker Company Name/Employer Your Job From To Reason for Leaving<br />
PLEASE TELL US ABOUT THE <strong>VOLUNTEER</strong> WORK YOU HAVE DONE:<br />
Organization Your Title/Placement From To Reason for Leaving<br />
Have you ever applied to volunteer with this organization before? ڤ Yes ڤ No<br />
If yes, When?<br />
PLEASE CHECK (√) WHICH AREA YOU ARE INTERESTED IN:<br />
ڤ<br />
Patient Care Programs ڤ Non Patient Care Programs ڤ<br />
Junior Volunteer Program (16-17 years of age) PLEASE INDICATE THE EXACT TIME (i.e. 9 –11am) YOU ARE AVAILABLE TO<br />
<strong>VOLUNTEER</strong>.<br />
Morning<br />
Afternoon<br />
Evening<br />
Monday Tuesday Wednesday Thursday Friday Saturday Sunday<br />
07/09/12
TIME COMMITMENT<br />
I am willing to make a commitment of a minimum of 3 months ڤ YES ڤ NO<br />
Please note the times of the year you are not available to volunteer (i.e. vacation)<br />
WHO WOULD YOU LIKE US TO CONTACT IN CASE OF AN EMERGENCY?<br />
Name:<br />
Phone: Home Work Cellular<br />
OPTIONAL<br />
If you wish to have anything further to be taken into consideration when determining a volunteer<br />
placement (for example: mobility issues, back problems or allergies) you may list those issues in<br />
the space provided.<br />
References, Photo Consent and Disclaimer<br />
If you are interviewed as a potential volunteer, you will be asked to provide three (3) references.<br />
Please note references from family members or from personal friends will not be accepted,<br />
unless you were employed by them.<br />
I hereby give the <strong>Victoria</strong> <strong>General</strong> <strong>Hospital</strong> and the Guild of <strong>Victoria</strong> <strong>General</strong> <strong>Hospital</strong> the<br />
absolute right and permission to copyright and/or publicize, or use photographic portraits or<br />
pictures of me, or videotaped images in which I may be included in whole or part for the use of<br />
advertising, art, trade and any other lawful purpose whatsoever.<br />
By submitting this application, I agree that the information I have provided on the form is true<br />
and accurate. Furthermore, I understand and agree that submitting this application form does<br />
not automatically register me as a volunteer. It is the policy of <strong>Victoria</strong> <strong>General</strong> <strong>Hospital</strong><br />
Volunteer Services to screen all prospective volunteers. While we try to place every prospective<br />
volunteer, management reserves the right to decline applicants who do not meet our<br />
requirements and/or placement criteria. I consent to this information and information about my<br />
volunteer work with <strong>Victoria</strong> <strong>General</strong> <strong>Hospital</strong> to be maintained on the Volgistics website and<br />
absolve and release <strong>Victoria</strong> <strong>General</strong> <strong>Hospital</strong> from all and any liability that may otherwise<br />
accrue by reason of keeping this information on the Volgistics website and using this<br />
information for <strong>Victoria</strong> <strong>General</strong> <strong>Hospital</strong> purposes.<br />
Signature: __________________________________<br />
Date: ____________________<br />
07/09/12
For applicants under the age of 18, parental/guardian consent is required before<br />
submitting this application.<br />
I consent to this information and information about my child/ward’s volunteer work with <strong>Victoria</strong><br />
<strong>General</strong> <strong>Hospital</strong> to be maintained on the Volgistics website and absolve and release <strong>Victoria</strong><br />
<strong>General</strong> <strong>Hospital</strong> and the WRHA from all and any liability that may otherwise accrue by reason<br />
of keeping this information on the Volgistics website and using this information for <strong>Victoria</strong><br />
<strong>General</strong> <strong>Hospital</strong> purposes.<br />
I, _________________________________ hereby give my permission for<br />
(print name of parent/guardian)<br />
_________________________________ to volunteer for <strong>Victoria</strong> <strong>General</strong> <strong>Hospital</strong>.<br />
(name of applicant)<br />
I have read and understood the Authorization and Consent as well as the Disclaimer and I<br />
consent to the details on my child/ward’s volunteering being stored on the Volgistics website as<br />
described above.<br />
NOTE:<br />
Parents may be advised of performance issues or in the event that disciplinary action should be<br />
required.<br />
Date___________________ _____________________________________<br />
(signature of parent/guardian)<br />
07/09/12