First Name

Last Name

Salutation Mr.Mrs.MissMs.Other (specify):

Home Phone

Cell Phone

E-mail

Street Address

City

Province

Postal Code

Date of Birth

Languages Spoken EnglishFrench (specify):

Name of Emergency Contact

Relationship

Phone of Emergency Contact

Health Status Declaration I confirm I am in good general health and able to perform volunteer dutiesI have a medical condition, but it does not affect my ability to volunteerI may require accommodations (please discuss with coordinator)Prefer not to disclose

Have you ever been convicted of a criminal offence for which a pardon has not been granted? YesNo

Are you willing to agree to a Canadian Police information check? YesNo

What volunteering postion(s) are you most interested in? Palliative Support VolunteerFriendly Visitor VolunteerBereavement VolunteerFundraising/Events Volunteer

Please upload your resume here

List 2 non-related person who will provide a reference for you

Reference #1

Name

Relationship

Phone Number

Email

Reference #2

Name

Relationship

Phone Number

Email

I, undersigned, authorize my reference to give information to Near North Palliative Care Network regarding my application to become a volunteer.