VOLUNTEER APPLICATION FORM Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Other Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Telephone Number*Business Telephone NumberCell NumberEmail Address EMERGENCY CONTACT INFORMATIONEmergency Contact Name* First Last Relationship to Volunteer* Emergency Contact Telephone Number*Alternate Telephone Number*INFORMATION ABOUT YOUEmployment Status* Employed Not Employed Retired Student Do you have a valid driver's license?* Yes No Do you have car insurance?* Yes No Do you have regular access to a car? Yes No Would you agree to undergo another security check at a future date?* Yes No Do you have any criminal convictions that have not been pardoned?* Yes No How did you learn about volunteering at Hospice Vaughan?* Why do you want to be a volunteer with Hospice Vaughan?*Give a brief description.Morning Availability* Sunday Monday Tuesday Wednesday Thursday Friday Saturday Not Available Afternoon Availability* Sunday Monday Tuesday Wednesday Thursday Friday Saturday Not Available Evening Availability* Sunday Monday Tuesday Wednesday Thursday Friday Saturday Not Available Do you speak and/or write any languages other than English?* Yes No If yes, please specify which language(s) spoken.* If yes, please specify which language(s) written: Please list which culture(s) you are familiar with.* Please list any special interests, hobbies, training, or skills that you have that will be relevant to your role here at Hospice Vaughan.* Do you have any previous or present volunteer positions? If yes, please list them here.* In which capacity would you like to volunteer?*(Please check all that apply) Virtual/In-Office Administrative Support Reception (Hospice Residence) Family and Residential Care (Hospice Residence) In-Home Visiting Program Adult Grief and Bereavement Support Groups Children's Programs “Caring Hands” Day Program Complementary Therapy (Yoga, Reiki, Meditation and Mindfulness, Other) Occasional Skill Sharing (e.g. Cooking Class, Crafts, Gardening, etc.) Kitchen and Nutrition (Hospice Residence) Environmental Services (Light Janitorial and Maintenance Work) Outreach, Special Events and Fundraising Marketing and Social Media For In-Home Visiting volunteers, would you feel comfortable volunteering with clients with:(Please check all that apply) Cancer Lung Disease A.L.S. Kidney Disease Heart Disease HIV/AIDS Are you comfortable volunteering with clients who:*(Please check all that apply) Smoke Have Pets Male Female Are you or have you been a client of Hospice Vaughan (or another Hospice)?* Yes No If yes, when and in what capacity? Have you had a person close to you die within the last year? Yes No Have you had any experience with death, dying, palliative care, or terminal illness? Yes No If yes, please explain briefly. Are you willing to complete our mandatory training program and commit to ongoing educational opportunities?* Yes No Do you have any medical limitations that should be considered in relation to how you can help others?* REFERENCES - Please provide two references whom we may contactPlease list a professional reference. This can be a manager, supervisor, coworker, teacher, counselor etc.Name* First Last Relationship* Years Known* Phone*Email* Please list a personal reference. This can be a friend, neighbour, volunteer, etc. (Note: this should not be a family member).Name* First Last Relationship* Years Known* Phone*Email* I AGREE THAT THIS FORM IS ACCURATE AND TRUE* Yes No
