Near North Palliative Care Network

Are you a placement student with NNPCN?YesNo

Salutation: Mr.Mrs.MissMs.Other. Specify:

First Name:

Last Name:

Middle Name:

Home Phone:

Cell Phone:

Work Phone:

E-mail:

FAX #:

Street Address:

Complement:

City:

Province:

Postal Code:

Date of Birth (Month/Day/Year):

Languages Spoken:
EnglishFrench
Other (specify):

Vaccination Status: Single Vaccinated.Double VaccinatedDouble + BoosterUnvaccinated

Name of Emergency Contact:

Relationship:

Phone of Emergency Contact:

Highest Educational Level:
High SchoolCollegeUniversity
completeincomplete

Palliative Care Training Courses Taken:

Bereavement and Grief Training Courses Taken:

Resumé (copy and paste your Resumé here):

Resumé (upload your Resumé here ):

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

Are there any clients you would not wish to visit?
YesNo

If yes, explain.

Which of the following activities would you be willing to volunteer?

Client Work
Visiting with Palliative Clients/FamiliesOvernight RespiteWeekend RespiteHoliday and Seasons RespiteRecreational TherapyTherapeutic Support (animal therapy, music therapy, laugh therapy, colour therapy, therapeutic touch, etc)Anticipatory Grief
Your Line of Therapeutic Support (specify):
Bereavement and Grief Support:
Individual SessionsGroup Sessions

Non-Client Work
Administrative Work at the OfficeAdministrative Work from HomeWebsite MaintenanceNewsletter WriterSocial Media Communication (Facebook, Twitter, YouTube)Event PlanningGrants/ProposalsData Collection and StatisticsGeneral Work at the Office

Board and Committees
Community Engagement and FundraisingFinance and BudgetGovernance, By-Laws, Policies and ProceduresQuality Assurance, Staff and Volunteer ManagementSponsorships and AlliancesCorporate Strategy, Program Development and EvaluationSatellite Offices (Mattawa, Sturgeon Falls)Education and TrainingBoard of Directors

What prompted your interest in volunteering for Near North Palliative Care Network?

Where did you hear about our upcoming Volunteer Training (if applicable):
WebsiteFacebookTwitter
Other (specify)

Have you experienced the death of a relative or close friends in the past year?
YesNo
If yes, state relationship:

List three non-related people who will provide a reference for you, including one work-related and one volunteer coordinator (if applicable).

Reference #1

Name

Relationship

City

Province

Phone Number

Email

Reference #2

Name

Relationship

City

Province

Phone Number

Email

Reference #3

Name

Relationship

City

Province

Phone Number

Email

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