Please complete this application form if you are interested in becoming a volunteer at Dryden Regional Health Centre. Once you complete the form, click the "continue" button at the bottom of the screen to submit it.

Name and address

First name:

Last name:

Title:

Street 1:

Street 2:

City:

Province:

* Postal code: *

Home phone:

Email address:

Best time to contact me

Demographic Information

Please provide the following information. This information is used for cards, mailings and statistics.

Date of birth:

Why are you interested in volunteering at Dryden Regional Health Centre?

Emergency Contact

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

Is there any other information that you would like us to know? (i.e. disabilities, preferences, etc.)

Education

Please list your previous education.

Employment History

1

2

Employer name:

Please list any professional skills that you would like to use in the volunteer role with us.

Special Skills/Training/Background

Please list any special skills you wish to utilize in your volunteer role.

Previous Volunteer Experience

Please list any previous volunteering that you have done.

References

Two references are required. References should include past or present employers, volunteer coordinators, teachers, etc. (We prefer that you not list family members or personal friends as references.)

1

2

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

Availability

Please indicate the days and times you are usually available to volunteer.

Which Volunteer Programs are you interested in?

*Please note that to volunteer directly with in-patients, you must be 16 years of age. Volunteers 14-16 years of age may volunteer as Greeters or may be utilized for special projects that do not involve direct patient contact.

Please list any specific areas you wish to volunteer in.

Volunteer Confidentiality Agreement

At all times, the privacy and dignity of clients, visitors, volunteers and staff will be respected. As a volunteer of the Dryden Regional Health Centre, you may have access to information and documents relating to the clients, volunteers and staff that are private and confidential in nature. All client records are the property of the Hospital and will be treated as confidential material; reasonable care and caution should be exercised to protect and maintain total confidentiality. No person shall read records or discuss such information unless there is a legitimate purpose. Client interactions shall not be discussed with people outside the Hospital, including immediate family members, throughout and beyond tenure with the Hospital. Neither volunteers nor staff will give medical advice (including comments and suggestions that personalize medical information and influence treatment decisions), but give pre-approved information regarding the Hospital and it's services.

I hereby authorize the Volunteer Services Department of the Dryden Regional Health Centre to contact the above named references. I hereby release them and their hospital from all liability. I further authorize the Volunteer Services Department of the Dryden Regional Health Centre to maintain this information in their records. Volunteers are expected to respect confidential information and to honour the agreed upon commitment.

By checking the "I agree" box below and submitting my application, I understand that I must serve with and under the supervision of Volunteer Services and the Coordinator of Volunteer Services. I will abide by the policies and regulations of the Dryden Regional Health Centre. The hospital is not obligated to provide placement, nor am I obligated to accept the placement offered.

I Agree