PERSONAL INFORMATION

Transcription

1 VOLUNTEER APPLICATION FORM PERSONAL INFORMATION Last Name: Street Address: City: Postal Code: Cell Phone: First Name: Apt. No. Province Home Phone: (print): Languages: English French Other: written spoken fluent spoken limited written spoken fluent spoken limited written spoken fluent spoken limited Have you included an updated résumé with this application? Yes No COMMUNITY INVOLVEMENT Community/Extra-Curricular Involvement: Please describe your current/recent volunteer commitments (organization, role, and length of involvement): AVAILABILITY Please indicate when you are available to volunteer. During the summer months, priority is given to high school students: Year-round September - June High School Students: July and August July Only August Only Would you like to volunteer: Full-Day each week Half-Day each week Two days each week December 2015 Page 1 of 5

2 Please place an X in all of the days and times when you would be available to volunteer: Morning (9 a.m. 12 p.m.) Afternoon (1 p.m. 4 p.m.) Evening (4 p.m. 8 p.m.) Monday Tuesday Wednesday Thursday Friday Saturday Sunday How many times can you volunteer per week (a commitment of at least one half-day per week is required): Please identify any restrictions you might have in fulfilling this commitment (vacation / extended periods of leave/ summer school etc.): Students: Current School: Year/Grade: Program: Full time Part time What career path are you considering: Adults: Current Employer: Position: Retired Full time Part time What do you hope to accomplish by volunteering at CHEO [please check all boxes that apply]: I enjoy working in new situations, taking on different activities, or helping in new ways, based on current needs. I hope to meet other people like me and expand my social network. I am interested in a career in a hospital. Before I make my final decision, I wish to spend time making sure that the hospital environment is a good place for me. I hope to use volunteer service to work through the loss of a loved one. I want to volunteer to improve my English/ French language skills. I hope that my volunteer work will lead to a job at CHEO. TELL US ABOUT YOURSELF Why do you want to volunteer at CHEO? If you were a super hero, what would your superpower be and why? December 2015 Page 2 of 5

3 Please select the volunteer roles that are of most interest to you (please review the detailed volunteer role descriptions listed on the CHEO Volunteer website): Outpatient Clinic Support (15yrs +) Healing Garden (15 yrs +) Peak Season Screener (18 yrs +) Inpatient - Playroom Support (15yrs +) Communications/Public Relations Day Care Surgery Parental Support Call Agent - Day Care Surgery (18 yrs +) MyChart Enrollment Ambassador Emergency Dept. Human Resources support (18yrs +) In-Patient Unit Companion Complex Care Companion Pharmacy Patient Safety Ambassador Physiotherapy / Occupational Therapy / Speech Language Pathology/ Audiology (18 yrs +) Reader (15yrs +) Butterfly Garden (15yrs +) Media House support (18 yrs +) Information Desk (15yrs +) Mental Health Services YouthNet (15 yrs +) Volunteer Resources Support Finance (18 yrs +) ICU Companion (18 yrs+) Where I am most needed Genetics (18 yrs +) Project Linus Greeter (15yrs +) How do you think you can best support our patients, families and staff? Is there any information that we should take into consideration to meet your needs as a possible CHEO volunteer? APPLICATION REQUIREMENTS As an applicant, please submit the following documents with your application. Please note that having this information when you apply significantly expedites the application process: Immunization status: Proof of a vaccination record or immunity from a blood test for mumps, measles, rubella (MMR) and chicken pox is required. Please note that a history of having had mumps, measles, rubella and/or chicken pox or shingles, is not an acceptable proof of immunity. A Health Care Provider (family doctor, walk-in clinic, College / University Health Services) may assist with obtaining these requirements. Police Records Check for Service with Vulnerable Sector: If you have a current Police Records Check for Service with the Vulnerable Sector completed within the last two years, please submit a copy with this application form in order to expedite the process. If you don t have this, you will be provided with a letter from CHEO if you are accepted as a volunteer to obtain one, free of charge, from the Ottawa Police Service. December 2015 Page 3 of 5

4 References: Please provide the names of two (2) individuals who have known you personally or professionally for more than one year that we may contact. References must not be family relatives. Reference #1 Reference #2 Name: Phone #: Relationship to you: Name: Phone #: Relationship to you: If you are accepted as a CHEO volunteer: You will be required to complete and submit the following requirements. Any costs for these requirements are the responsibility of the applicant / volunteer except as noted. Tuberculosis Testing: A 2-step tuberculosis skin test (2 injections, 2 examinations = 4 appointments), completed within the last 12 months. Candidates who test positive must submit the results of a negative chest x-ray report, completed within the last 5 years. A Health Care Provider (family doctor, walk-in clinic, College / University Health Services) may assist you with obtaining these requirements. Police Records Check for Service with the Vulnerable Sector: CHEO can accept an existing Police Records Check for Service with the Vulnerable Sector completed within the last two years. Once accepted as a CHEO volunteer, CHEO will provide a letter to accepted candidates to waive the fee. VOLUNTEER AGREEMENT CHECKLIST I have carefully considered my schedule, and know that I can commit to volunteer for the times I indicated above. I know that the children and youth I might see at CHEO may be very sick. I am comfortable being with and around them, even though they may be experiencing discomfort. I am able to establish personal and professional boundaries (i.e. refrain from offering personal advice or personal experiences to patients). I treat volunteer commitments with the same respect that I do with school/work responsibilities, committing to a regular day and time. I understand that I may not be contacted for an interview and that participating in an interview does not guarantee acceptance to the program. I understand that accepted candidates will be required to comply with the application requirements and that it is the applicants responsibility to pay for any expenses associated with these requirements. I understand that I will not be paid for my involvement as a volunteer. December 2015 Page 4 of 5

5 I acknowledge that the statements made in this application are true and correct, and have been given freely. Patient's medical information is strictly confidential and must never be discussed unnecessarily with others. As a volunteer at CHEO, all information concerning patients, family, visitors and staff will be held in confidence. Disclosure of confidential information shall be subject to disciplinary action up to and including discharge. Applicant s signature Date (Month / Day / Year) Parent / Guardian s signature Date (Month / Day / Year) (If applicant is 17 years or younger) Please submit your completed application form and attachments to: VResources@cheo.on.ca CHEO is committed to providing accessible volunteer opportunities that comply with the Accessibility for Ontarians with Disabilities Act (AODA). Please notify us, if you require accommodation for disability during any stage of the volunteer intake process. The personal information you provide to us on this form is required for you to become a volunteer at CHEO and will be used to communicate with you for volunteer activities. It will be kept confidential. If accepted as a volunteer, your personal information will be shared with the CHEO Volunteer Association, of which all active volunteers are members. If you have questions please contact CHEO s Privacy Office at privacy@cheo.on.ca or ext All inquiries will be kept confidential. December 2015 Page 5 of 5