Volunteer Registration Form Name(Required) Address(Required) Home/Cell Phone(Required) Alternative Phone Email Address(Required) What type of volunteer role are you interested in? (Select all that apply.) Recreation Volunteer Therapy Volunteer Board Volunteer General Volunteer Support Services Volunteer CTC-CK Foundation Volunteer Availability Are you interested in working with a designated program? If so, select all programs that apply. Speech Physiotherapy Occupational Therapy Recreation Pool What languages other than English do you write and/or speak with ease? Describe the skills or interests you would be able to share (crafts, art, scrapbooking, hobbies, computers) Emergency Contact - Person to contact in case of emergency Emergency Contact Address Emergency Contact Phone Number Personal Reference 1: Name Personal Reference 1: Relationship Personal Reference 1: Contact Information (Please include phone number and email address) Permission to be contacted by the CTC-CK I give concent for the CTC-CK to contact me by email or phone regarding volunteering Yes No AgreementsEmail Distribution List Yes, add me to your email distribution list so I will receive emails when volunteer opportunities arise. To withdraw your consent, please email: cbottrill@ctc-ck.com Permission to Contact above References(Required) I give my permission to the Volunteer Coordinator to contact the above references in regards to my application after the completion of the interview. I further confirm that the above information is true to the best of my knowledge. I understand that any information collected by CTC-CK will be kept confidential and will not be passed on to any person or agency without my express permission. By checking the box, you agree to abide by our Confidentially Agreement.(Required) I understand that: all confidential and/or personal health information that I have access to or learn through my employment or affiliation with Children's Treatment Centre of Chatham-Kent is confidential, as a condition of my employment or affiliation with Children's Treatment Centre of Chatham-Kent, I must comply with these policies and procedures, and my failure to comply may result in the termination of my employment or affiliation with Children's Treatment Centre of Chatham-Kent and may also result in legal action being taken against me by Children's Treatment of Chatham-Kent and others. I agree that:(Required) I will not access, use or disclose any confidential and/or personal health information that I learn of or possess because of my affiliation with Children's Treatment Centre of Chatham-Kent, unless it is necessary for me to do so in order to perform my job responsibilities. I also understand that under no circumstances may confidential and/or personal health information be communicated either within or outside of Children's Treatment Centre of Chatham-Kent, except to other persons who are authorized by Children's Treatment Centre of Chatham-Kent to receive such information. I agree that:(Required) I will not alter, destroy, copy or interfere with this information, except with authorization and in accordance with the policies and procedures of Children's Treatment Cnetre of Chatham-Kent. I agree that:(Required) Keep any computer access codes (for example, passwords) confidential and secure. I will protect physical access devices (for example, keys and badges) and the confidentiality of any information being accessed. I agree to:(Required) Not lend my access codes or devices to anyone, nor will I attempt to use those of others. I understand that access codes come with legal responsibilities and that I am accountable for all work done under these codes. If I have reason to believe that my access codes or devices have been compromised or stolen, I will immediately contact the Children's Treatment Centre of Chatham-Kent.
