Please complete this application form if you are interested in becoming a volunteer at one of the County of Simcoe's long-term care facilities. Once you complete the form, click the submit button at the bottom.

Contact Information

Please complete the contact information.

First Name:

Last Name:

Type:

Kind:

Individual Group

Address 1:

City:

Province:

* Postal code: *

Preferred Number phone:

2nd Number phone:

Cell phone:

Email address:

Date of birth:

(year optional)

Gender:

Date of Application:

What kinds of email would you like to receive?

Previous Volunteer Experience

Summarize your previous volunteer experience.

Special Skills and Qualifications

Summarize special skills and qualifications you have acquired through employment, previous volunteer work or through other activities including hobbies or sports.

Interests

Tell us in which areas you are interested in volunteering. The services in which you are able to participate will be determined by your availability, your skills and experiences as well as by our current vacancies. This will be discussed further during your interview.

Availability

During which hours are you available for volunteer assignments?

Emergency Contact Information

Please complete the emergency contact information.

First name:

Last name:

Title:

Address 1:

City:

Province:

Postal code:

1st Contact Number phone:

2nd Contact Number phone:

Email address:

Relationship:

References

Please provide two references. (NOTE: relatives are not accepted.)

First name:

Last name:

Title:

Address 1:

City:

Province:

Postal code:

1st Contact Number phone:

2nd Contact Number phone:

Email address:

Where did you hear about us?

Please indicate how you heard about us?

Agreement and Signature

Volunteers play a vital role in the care and services we provide to the Residents we serve in our Long-Term Care Homes. As one of our volunteers, we extend a sincere thank you for all the time that you give to enrich the lives of so many individuals. We ask that you please sign below after reviewing the following information to ensure consistent standards in our volunteer program. Thank you.

As a valued volunteer, I fully understand and agree to the following:

• For my efforts, I do not expect any monetary remuneration, salary, wage, payment or any employee benefits and understand that I am not covered by the Worker’s Safety and Insurance Act.

• For the protection of all parties, I will not use any equipment that requires prior knowledge and/or formalized training, except after I have been authorized and trained to use it. If there is any question about this, I will not use the equipment until I have been authorized to do so.

• I will follow the health and safety guidelines and other directives of the County, as well as any legislative requirements that were explained in my initial orientation as a volunteer, or at any other time during my volunteer efforts with the home.

• I assume any risk to myself that may result directly or indirectly from my volunteer activities while on County of Simcoe property. In the event that I become injured or ill while engaged in my volunteer capacity for the Home, I will not hold the Corporation of the County of Simcoe responsible. The Corporation of the County of Simcoe takes pride in and is responsible to ensure a safe and secure environment for our Residents, their families, volunteers and staff.

• In the course of participating in the volunteer program, I may be in receipt or have knowledge of confidential information including, but not limited to, client identities, material, records, memoranda, personal health information, data and results pertaining to, arising from, or containing particulars of, confidential information. I agree that I shall not at any time while I am providing volunteer services for the County of Simcoe, or at any time after those services are completed, disclose to anyone any confidential information, except as may be required or permitted by law, or at the request of the County of Simcoe, or as required to perform volunteer services.

• I have read this release, been given a reasonable opportunity to seek independent legal advice, and understand all of its terms; I sign it voluntarily, with full knowledge of its significance.

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.

I Agree