Name: Resume Attached(optional): Yes No

Phone (residence): Phone (business):

E-mail Address:

Address:

Street Apt# City

Province Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nunavut Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code

Birthday (year optional):

REFERENCES

Please supply two references that can be contacted.If nominated Please include nominator.

Please Note: As an agency serving frail seniors, we must check references for all volunteers.
Normally we do not assign duties that require one on one involvement with seniors in their own home or transportation of clients, when this is the case we must also do a Police Check, including driving record.

Reference # 1

Name Phone

Relationship

Address

Reference #2

Name Phone

Relationship

Address

In what capacity are you interested in volunteering?

Program(s): Service Volunteer Companion Talent Sharing Special Events Board of Directors Triple S Program Camp Sunshine

Availability:

Tasks:

Please fill out the following in case of an emergency:

Emergency Contact: Relationship

Phone: Family Doctor:

Phone: Ontario Health Card #:

Do you have any medical information (allergies etc.) that Sunshine Centres For Seniors should be aware of Yes No

If Yes, please describe

CONFIDENTIALITY CLAUSE

I agree to hold in confidence all confidential matters that come to my attention while serving as a volunteer with the Sunshine Centres for Seniors. This especially includes personal information with regards to members. Futhermore, I will use in a responsible manner, information gained in the course of my volunteer placement.

I HAVE READ, UNDERSTAND AND WILL ABIDE BY THE FOREGOING.

I Agree

WAIVER

I acknowledge that participation in or attendance at the programs, activities or events of Sunshine Centres for Seniors may involve certain risks due to the possibility of accidents and that I am solely responsible for my personal safety, well being and health while participating in or attending any such program, activity or events. I understand that photos taken during programs
may be used by SCS for publicity or fund raising purposes only and hereby grant permission for their use.

In consideration of my being permitted to participate in or attend such programs, activities or events, I and my heirs, release and indemnify Sunshine Centres for Seniors, their directors, employees and volunteers and volunteers against lawsuits, claims or costs as a result of anything that may happen to me or my property as a result of my Participation or attendance.

I understand that by submitting this form I agree to the previous terms and conditions and by agreeing with this I am applying my electronic signature.

I Agree