Volunteer Registration Form

Every item that has an * must be filled out. There are drop down menus for some items.

Section 1 - Contact Information

First Name*

Middle Name

Last Name*

Street Address*

City*

Province*

Postal Code*

Email*

I give my consent to receive emails regarding volunteering with SCHC and its programs:* Yes No

Phone Number*

Text Messages?:* Yes No

Major Intersection*

Section 2 - Roles Roles below in drop down menu are urgently needed. Please tell us your 1st choice & if you’re willing to do a 2nd or 3rd role. NOTE: If none of these interest you, skip to the additional roles listed below and indicate your choice. Please take note of days and times listed with each role
First priority
Second priority
Third priority
Please indicate your interest below, if any. Be selective and only indicate 2-3 choices at most: Roles Available Monday to Friday 9am-5pm ONLY: These Roles are Occasional, Evenings & Weekends:

Section 3 - Availablity Your availability should only be selected based on the roles chosen. If multiple roles are selected, please select any time you are available to volunteer, based on the roles

Monday	Morning	Afternoon	Evening	All
Tuesday	Morning	Afternoon	Evening	All
Wednesday	Morning	Afternoon	Evening	All
Thursday	Morning	Afternoon	Evening	All
Friday	Morning	Afternoon	Evening	All
Saturday	Morning	Afternoon		All
Sunday	Morning	Afternoon		All

Commitment *

Section 4 - About you
Age *	What language [other than english] do you speak/ write with ease?
Do you have a current Police Check?* Yes No If you answered 'No' above, do you consent to get one done? It is mandatory & we will supply required form: Yes No Mode of transportation?:* Your own vehicle/car Public Transit
How did you hear about SCHC?* ANC CHC Community Centre Friend/Family Local Newspaper Other Our other locations Our Website Public Library Service User Social Media Volunteer Toronto Charity Village Flyer

Section 5 - About volunteering
Please tell us why you are interested in volunteering in the role(s) you’ve indicated & what you hope to gain from the experience *
Briefly outline your work/volunteer/school experience

Section 6 - Experience & Limitations
Have you had work or volunteer experience: With seniors? * Yes No With children?* Yes No With dementia?* Yes No With a chronic and/or life-limiting illness patient?* Yes No Do you have any training or education in: Diversity/Equity/Inclusion?* Yes No If yes, give details: Do you require any accommodations or assistance in the event of an emergency evacuation?* Yes No Do you have any allergies? * Yes No If yes, give details: Do you have any limitations or health issues which may affect your ability to volunteer and that you would like us to consider when placing you in a volunteer position?*

Section 6 - Experience & Limitations

Have you had work or volunteer experience:
With seniors? * Yes No
With children?* Yes No
With dementia?* Yes No
With a chronic and/or life-limiting illness patient?* Yes No

Do you have any training or education in: Diversity/Equity/Inclusion?* Yes No
If yes, give details:

Do you require any accommodations or assistance in the event of an emergency evacuation?* Yes No

Do you have any allergies? * Yes No
If yes, give details:

Do you have any limitations or health issues which may affect your ability to volunteer and that you would like us to consider when placing you in a volunteer position?*

Section 7 - Emergency Contact
Emergency Contact
Name*	Relationship to You*
Phone Number*	Email

Section 8 - ReferencesReferences must be provided - 2 please. Do not use relatives.
First Reference
First Name*	Last Name*
Relationship to You*
Phone Number	Email
Second Reference
First Name	Last Name
Relationship to You
Phone Number	Email

Section 9 - Consent
I consent to have my photograph used by Scarborough Centre for Healthy Communities: * Yes No Information collected on this authorized form complies with the Privacy Act and Personal Health Information Protection Act. SCHC collects information to assist with program planning, improvement of services, and research. This information is confidential and shall not be used for purposes other than those for which it was collected, nor shall any identifying information be sent externally, except with your expressed consent or as required by law. We encourage you to discuss any questions you may have with one of our staff. By checking the box above you are verifying that the information provided is true and complete. You give us permission to obtain personal information from your listed references. False statements and omissions are grounds to terminate the volunteer role. I agree to follow SCHC policies & procedures. Failure to do so will result in termination of the volunteer role.

Section 9 - Consent

I consent to have my photograph used by Scarborough Centre for Healthy Communities: * Yes No
Information collected on this authorized form complies with the Privacy Act and Personal Health Information Protection Act. SCHC collects information to assist with program planning, improvement of services, and research. This information is confidential and shall not be used for purposes other than those for which it was collected, nor shall any identifying information be sent externally, except with your expressed consent or as required by law. We encourage you to discuss any questions you may have with one of our staff. By checking the box above you are verifying that the information provided is true and complete. You give us permission to obtain personal information from your listed references. False statements and omissions are grounds to terminate the volunteer role. I agree to follow SCHC policies & procedures. Failure to do so will result in termination of the volunteer role.

Section 10 - For Hospice Home Visiting, Friendly Visiting, Bereavement Care & Caregiver Support roles
Do you have any personal experience caring for someone to the end of life? * Yes No Have you had a person close to you die within the last year?* Yes No If yes, did you seek any kind of bereavement support?* Yes No Do you have a valid Driver’s License and access to a vehicle* Yes No A copy of your license and up-to-date insurance coverage will be required if you say Yes Are you willing to drive a client if required?* Yes No Do you have any training or education in: Hospice Palliative Care?* Yes No Grief & Bereavement?* Yes No Group Facilitation?* Yes No If yes, give details: To help us with matching you with a service user, please tell us a bit about yourself* Describe your experiences with cultural diversity including spiritual/religious/faith practices related to illness, death, dying and bereavement: What are your hobbies/interests? (e.g. sports, music, crafts, board games). Please check all that apply. Other Skills Willing to visit a client: with pets? * Yes No who smokes?* Yes No Are you able to make a ONE YEAR COMMITMENT to volunteering (with time off for vacation, breaks etc.)? * Yes No I understand that completion of all training (both online and in person) as well as a clear Vulnerable Sector Police check is required in order to be placed with one of the four roles listed above and I agree to follow the guidelines of the Community Hospice & Friendly Visiting Programs provided to me as part of the training process* Yes No Religion

Section 10 - For Hospice Home Visiting, Friendly Visiting, Bereavement Care & Caregiver Support roles

Do you have any personal experience caring for someone to the end of life? * Yes No

Have you had a person close to you die within the last year?* Yes No
If yes, did you seek any kind of bereavement support?* Yes No

Do you have a valid Driver’s License and access to a vehicle* Yes No
A copy of your license and up-to-date insurance coverage will be required if you say Yes
Are you willing to drive a client if required?* Yes No

Do you have any training or education in:
Hospice Palliative Care?* Yes No
Grief & Bereavement?* Yes No
Group Facilitation?* Yes No
If yes, give details:

To help us with matching you with a service user, please tell us a bit about yourself* Describe your experiences with cultural diversity including spiritual/religious/faith practices related to illness, death, dying and bereavement:

What are your hobbies/interests? (e.g. sports, music, crafts, board games). Please check all that apply.

Other Skills

Willing to visit a client:
with pets? * Yes No
who smokes?* Yes No

Are you able to make a ONE YEAR COMMITMENT to volunteering (with time off for vacation, breaks etc.)? * Yes No

I understand that completion of all training (both online and in person) as well as a clear Vulnerable Sector Police check is required in order to be placed with one of the four roles listed above and I agree to follow the guidelines of the Community Hospice & Friendly Visiting Programs provided to me as part of the training process* Yes No
Religion

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