Volunteer Application Form

Please complete this application form if you are interested in becoming a Westminster Canterbury Richmond volunteer. Fields marked with an asterisk are required; the others are optional. Once you complete the form, click the continue button at the bottom.


Name and address


Current/Past Employment and Volunteer Experience

Please include any previous experience working with older adults.



Education


Knowledge of Westminster Canterbury

Have you ever worked or volunteered for Westminster Canterbury? If yes, when? If no, how did you learn about us?



Skills/Areas of Interest


Availability


Emergency Contact

(must list at least one phone number)



References

(should not be relatives)



Criminal Record Statement #1

Have you ever been convicted of a felony, misdemeanor, including moving traffic violations? If yes, please explain.



Criminal Record Statement #2

Are you the subject of any pending criminal charges? If yes, please explain.



Criminal Record Statement #3

Have you ever been convicted of patient abuse and/or convicted of health care fraud? If yes, please explain.



Volunteer Statement

CERTIFICATION: Please read the following information carefully. By checking the box below, you are agreeing to the following and thereby providing your electronic signature.

I certify that my answers to the foregoing questions and my statements are true, and that I have not omitted any material information.

I further understand that volunteering will be conditioned on my meeting requirements of a background check and/or a pre-employment screening, and that Westminster Canterbury will use the results only as permitted by law.

I agree to abide by the policies and procedures of Westminster Canterbury as outlined in the Volunteer Handbook.

I hereby release from all liability and responsibility all persons, corporations, institutions, and other entities that provide such information.


I understand that if I am accepted as a Volunteer at Westminster Canterbury Richmond, I will be prompt, reliable and follow the procedures outlined in the Volunteer Handbook.



Electronic Signature