Volunteer Application Form Name: Address: City: Phone: E-mail: First Language:
□ 340 College Street □ Post-op support □ Information
Apt. #: Postal Code: Date of Birth:
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Other Language(s):
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Potential Areas of Interest Kensington Gardens □ Kensington Hospice Pastoral/Religious □ Reception Services □ Nutrition Dining Assistance □ Complimentary Friendly Visitor Therapy Reception □ Music Care Café □ Resident & Life Enhancement Family Care and Special Events
□ Second Mile Club □ Friendly Visitor □ Medical and/or □ Translation □ Escort □ □ Program, □ Lunch, Special □ Events □ Transportation Assistant If you would like to volunteer in other ways, please specify: _____________________________
Why would you like to volunteer with Kensington Health?
Please list and describe your previous volunteer experience. (If any)
What are your special interests/hobbies?
How would you contribute to the quality of life for our clients/patients/residents?
Working with older adults and those who are dying can be very meaningful and can also remind us of our own lived experiences with loss. Have you had someone close to you die within the last year? â–Ą No Yes
Education Employment Experience
Are you currently a student? Yes No Name of School: Current Grade/Degree: Are you currently employed? Yes No Current Occupation and Employer:
By signing below, I acknowledge that I have read, understand, and agree to abide by the requirements set forth below: In order to protect the privacy of clients and residents, I agree and understand that as a volunteer, information that I might learn about the clients/residents and their families will be kept completely confidential. In order to provide safe and appropriate volunteer opportunities, I agree and understand that as a minimum requirements I must provide: o Complete an Interview o Complete a Vulnerable Sector Police Check (after the completion of the initial review of your suitability and/or you have tentatively been selected for a volunteer opportunity) – Please Note: Volunteers under 18 do not require a Police Check o Complete a Two-Step Mantoux Tuberculosis Skin Test o Provide 2 references o Attend and complete all the necessary training and orientation sessions or certifications I understand that the information provided in this application is part of the permanent volunteer file at Kensington Health Centre. Signature of Date: Volunteer: Note: Volunteers under the age of 18 are requested to provide parental consent Signature of Date: Parent/Guardian: