Application Form
PROFILE INFORMATION
Please complete the application form if you are interested in becoming a volunteer at the Queen Elizabeth Hospital.
First name:
*
Last name:
*
Title:
Choose
Mr.
Ms.
Street 1:
*
City:
*
Province:
Choose
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Postal code:
*
Home phone:
*
OK to call me here
Cell phone:
OK to call me here
Email address:
*
DEMOGRAPHIC INFORMATION
This information is only used to get a better idea of the demographic makeup of our volunteers.
Date of birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
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17
18
19
20
21
22
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24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
*
Gender:
Choose
Female
Male
Other
Education:
Choose
College
High school
University
Marital Status:
Choose
Common-Law
Divorced
Married
Single
Widowed
Current Grade:
Language:
Albanian
Arabic
Assyrian
Bosnian
Cantonese
Chinese
Cree
Croatian
Czech
Dutch
English
French
German
Hindi
Hungarian
Italian
Japanese
Korean
Latin
Mandarin
Other
Polish
Punjabi
Romanian
Russian
Serbian
Spanish
Swedish
WORK AND VOLUNTEER EXPERIENCE
Please describe any related work and/or volunteer experience.
HOBBIES AND INTERESTS
List your special skills, hobbies and interests.
WHY DO YOU WISH TO VOLUNTEER?
Please indicate why you are considering volunteering.
EMERGENCY CONTACT
Please provide information for a contact person in case of an emergency.
1
2
First name:
First name:
Last name:
Last name:
Home phone:
Home phone:
Cell phone:
Cell phone:
REFERENCES
Please provide contact information for two references not related to you and that have known you for more than 12 months.
1
2
First name:
*
First name:
*
Last name:
*
Last name:
*
Home phone:
Home phone:
Work phone:
Work phone:
Email address:
*
Email address:
*
AVAILABILITY
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Morning:
Afternoon:
Evening:
Assignment Preference:
Admitting [Admitting]
Coffee Shop [Coffee Shop]
CTC [CTC]
Diagnostic Imaging [Diagnostic Imaging]
Emergency [Emergency]
Hair Care [Hair Care]
Hemodialysis [Hemodialysis]
Info Desk [Info Desk]
Mammography [Mammography]
Newspaper [Newspaper]
Pastoral Care [Pastoral Care]
Pediatrics [Pediatrics]
Pharmacy [Pharmacy]
Physical Medicine [Physical Medicine]
Pre-Surgery [Pre-Surgery]
Royal Pantry [Royal Pantry]
Shared Clinics [Shared Clinics]
Special Testing Services [Special Testing Services]
HEALTH
Do you have any health restrictions that might affect you as a volunteer at the hospital?
INFORMATION STORAGE
I consent to having my volunteer information stored on the Volgistics volunteer management system which is external to Health PEI.
I Agree
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