Volunteer Information Online – North Lambton Community Health Centre

Name

First Last

Occupation

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Best time to be contacted

Email

Please list all your current and past volunteer positions and experience

PLEASE PROVIDE TWO REFERENCES:

Name

First Last

Phone

Relationship

Name

First Last

Phone

Relationship

IN CASE OF EMERGENCY, PLEASE NOTIFY

Name

First Last

Phone

Relationship : (i.e. spouse, mother, etc.)

MEDICAL INFORMATION

Family Physician Name

First Last

Physician Phone

Do you have any medical conditions or other limitations we should know about?

WHERE DID YOU HEAR ABOUT OUR ORGANIZATION?

WHAT AREAS WITHIN THE CENTRE WOULD YOU BE INTERESTED IN VOLUNTEERING FOR?

Seniors Programs
Youth Programs
Social Activities
Garden Fresh Box
Transportation
Physical Fitness Programs
Cooking Programs
Administration

Volunteer Consent

I agree/ Consent.

I acknowledge and understand that this is an application to participate in a volunteer program for which there will be no financial compensation, and that attendance and work done by the volunteer at the NLCHC for the purposes of the program will be at the sole risk and expense of the volunteer