Volunteering at the Vic - Victoria General Hospital

VGH Web Sites:

Victoria General Hospital. Small Hospital. Big Heart. Clear Vision.

Online

Please tell us about yourself:

Title:
**First Name:
Middle Name:
**Last Name:
Preferred Name:
**Address:

**City:
**Province/State:
**Postal/Zip Code:
**Home Phone:	- - Ext.
Business Phone:	- - Ext.
Cell Phone:	- - Ext.
Fax Number:	- -
E-mail:
**I prefer to receive calls at:	Home Business Cell
**Best time to contact you:
SIN:
Date of Birth if under 18:

Please tell us about your education:

Formal education is not needed to be a volunteer. We welcome experience of all kinds!

	Name of School	Highest level obtained	Currently Attending?
Junior High			Yes No
High School			Yes No
Post Secondary - College/University			Yes No
Other			Yes No

**Are you receiving credit for your volunteer work?	Yes No
What school or organization do you require the hours for?
Required number of hours:

Please tell us about your employment history:

**Currently:	Employed Unemployed Retired Student Homemaker
**My employer offers a donating matching program:	Yes No
**My employer offers a time-off program for volunteers:	Yes No

Company Name/Employer	Your Job Title	From	To	Reason For Leaving

Please tell us about volunteer work you have done:

Organization	Your Title	From	To	Reason For Leaving

**Have you ever applied to volunteer with us before:	Yes No
If yes, when:

Please check which area(s) you are interested in:

**Area:	Patient Care Programs Non Patient Care Programs Junior Volunteer Programs (15 - 18 years of age)
If exact program/area known, please indicate:

What skills and experience do you have to offer?

**Skills & experience:	Clerical Communication skills Computer skills CPR Creative ideas Experience with the elderly Fundraising Languages spoken/read Musical instrument Nursing Organizational skills Photography Physical strengths Retail experience Special training Valid drivers licence Work well with people
Other, please specify:

What is/are your reason(s) for volunteering?

**Reasons:	Academic credit Employment experience Explore careers Increase self-esteem Learn new skills Help others Improve health care Social interaction Relative/friend volunteers Referred by medical profession Stay active & involved
Other, please specify:

How did you find out about our volunteer program?

**How I found out:	Physician Community Another volunteer Previously a patient Visited a patient Employee of this organization School Newspaper Volunteer center Poster/brochure/flyer Knew about/noticed department Human resource department Radio TV Referral organization Recruitment/information booth Relative/friend
Other, please specify:

Please enter the time periods you are available to volunteer (eg: 9am - 11am):

	Morning	Afternoon	Evening
Monday	-	-	-
Tuesday	-	-	-
Wednesday	-	-	-
Thursday	-	-	-
Friday	-	-	-
Saturday	-	-	-
Sunday	-	-	-

Time commitment:

**How long a commitment are you prepared to make?	3 months 6 months 1 year+
**How many times a week would you like to volunteer?	1 shift 2 - 3 shifts 4 or more
**Are you interested in volunteering for special projects or events?	Yes No
**Please note the times of the year that you are not available to volunteer:

Who would you like us to contact in case of an emergency?

**First Name:
**Last Name:
Relationship:
**Home Phone:	- -
Business Phone:	- - Ext.
Cell Phone:	- -

Health Information

Please list any intellectual or physical disabilities or health problems which may affect your ability to perform as a volunteer and that you wish to have taken into consideration when determining a job placement.

References

Please list three references - past or present employers, volunteer co-ordinators, teachers, etc. We cannot accept family members or personal friends as references.

Name	Relationship

Work Phone	Home Phone
- - Ext.	- -
Name	Relationship

Work Phone	Home Phone
- - Ext.	- -
Name	Relationship

Work Phone	Home Phone
- - Ext.	- -

I hereby authorize Victoria General Hospital permission to contact the above named references to ascertain my suitability as a volunteer. I hereby release Victoria General Hospital from all liability for any damage whatsoever for issuing same. I further authorize the Volunteer Department to maintain this information in their records and release and absolve them from all liability that may otherwise accrue by reason of their keeping this information and using it for their purpose.

Disclaimer: It is the policy of this organization to screen all prospective staff and volunteers. While we try to place every prospective volunteer, management reserves the right to reject applicants who do not meet our requirements and/or job placement criteria.

As a volunteer your photograph may be taken for hospital and/or Guild purposes. These photographs are used for items such as newsletters, photo contests, and newspaper articles. If you consent to your picture being used for these purposes please read the following statement.

I hereby give the Victoria General Hospital and the Guild of Victoria General Hospital the absolute right and permission to copyright and/or publicize, or use photographic portraits or pictures of me, or videotaped images in which I may be included in whole or part for the use of advertising, art, trade and any other lawful purpose whatsoever.

If you agree to the statements above, please check here