General Volunteer Application - Children's Treatment Centre

Name

First Last

Address

Street Address Address Line 2 City Province Postal Code

Home Phone

Alternative Phone

Email

What type of volunteer role are you interested in? (select all that apply)

Working directly with staff person
Helping with general administrative duties
Assisting with a therapist and client
Assisting with fundraising events
Family Advisory Council

Availability (select all that apply)

Daytime
Evening (after 5:00)
After School

Are you interested in working with a designated program? If so, please check all that apply:

Occupational Therapy
Physiotherapy
Social Work
Speech/Language Therapy
Recreation
Music
Audiology
Family Engagement

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)

Is there anything else you would like us to consider when matching you with an appropriate volunteer role?

Are you willing to provide a recent Criminal Reference Check (CRC) as part of the required screening process at time of interview? Once you complete 10 hours of volunteer work, we will reimburse you for your CRC.

Yes
No

Emergency Contact

Person to contact in case of an emergency

First Last

Emergency Contact Address

Street Address Address Line 2 City Province Postal Code

Emergency Contact Phone

Personal References

These individuals must be an adult, should have known you for more than 2 years and may not be a partner, spouse or family member.

Reference 1: Name

First Last

Reference 1: Relationship

Reference 1: Email

Reference 1: Home Phone

Reference 2: Name

First Last

Reference 2: Relationship

Reference 2: Email

Reference 2: Home Phone

Permission to be contacted by the CTC-CK

I give consent for the CTC-CK to contact me by email regarding volunteering

Agreements

Email 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@nullctc-ck.com.

Permission to Contact above References

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 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 Confidentiality Agreement.

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 Centre of Chatham-Kent and others.

I agree that:

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:

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 Centre of Chatham-Kent.

I agree to:

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:

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.

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