Volunteer Registration

Full Name

First Name

Last Name

Date of Birth

Phone Number

Email Address

Nationality

Immigration Status

Addresses

Postal Address

PO Box

City

ZIP / Postal Code

State / Province

Country

Permanent Address

Address

City

ZIP / Postal Code

State / Province

Country

Interests and Availability

Availability

How many hours per week are you available to work?

Schedule

What are your preferred days and times to volunteer?

Education and Work Experience

Employment History

Special skills and qualifications (summarized special skills, foreign language and qualifications you have acquired from education, employment, previous volunteer work, or through other activities):

Please list work experience of the past 5 years:

Employer

Dates Employed

Job Title

Role and Responsibilities

Emergency Information

Contact

Relationship

Emergency Contact Phone Number

Parental Consent (under the age of 18 only)

I have read this application and am consenting to my child’s involvement in volunteering, and I also give permission to the hospital to treat my child if medical attention should become necessary while volunteering.

Parent/Guardian Name

Date

Parent Phone Number

Documents

Please note that if you are selected for volunteer service, you will be required to present the following documents:

1 Professional reference, 1 Personal reference, Copy of Health Insurance, Police Clearance Certificate, Medical Certificate, Copy of passport/birth cert., Copies of qualifications

Personal Statement

Declaration

I declare that the preceding information is correct and true. I attach or can produce certificates of qualification(s) on request. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misinterpretations made by me on this application may result in my immediate dismissal.

Public Notice

HSA Smith Road Pharmacy closure Sunday Nov 24