Survey - Volunteer Questionnaire - St. Joseph's Health Centre Foundation

Contact Information

*

Name:

Title	First Required	Last Required

*

Email: Required

*

Street 1: Required

*

City/Province/Postal:

City Required	State Required	Postal Required

*

Phone Number: Required

If you respond and have not already registered, you will receive periodic updates and communications from St. Joseph's Health Centre Foundation.

Question - Not Required - Date of Birth (Optional)

Month

Day

Year

Question - Not Required - Why do you want to volunteer your time?

*

Question - Required - How would you like to volunteer?
Please make between 1 and 3 selections from the choices below.

	Event volunteer (e.g. Cycle 4 St Joe's, community events, etc)
	Committee volunteer (member of a fundraising committee)
	Skills-based volunteering (e.g. design, volunteer coordination, special project, etc. )

Question - Not Required - Were you born at St. Joesph's?

Yes

No

Question - Not Required - Were you a patient at St. Joesph's?

Yes

No

Question - Not Required - Is St. Joseph's your community hospital?

Yes

No

Question - Not Required - Employment / Education / Volunteer Experience
Please make between 1 and 3 selections from the choices below.

	Employed - Full time
	Employed - Part time
	Student
	Retired
	Other

Question - Not Required - Which Organization/Company are you a student or employee of:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Please tell us about your work and/or past volunteer experience:

Question - Not Required - Have you volunteered with the St. Joseph's Health Centre in the past?

Yes

No

Question - Not Required - In what capacity? (E.g. event, committee, skills-based volunteer):

EMERGENCY CONTACT (OPTIONAL)

Question - Not Required - Name:

Question - Not Required - Relation:

Question - Not Required - Home Phone:

Question - Not Required - Mobile Phone:

Disclaimer:

I certify that all information in this application form is true and complete. False statements or omissions are grounds to terminate the relationship no matter when they are discovered. I authorize the Foundation staff to contact the above references to determine my suitability for a volunteer position. If accepted as a volunteer, I agree to comply with the policies and procedures of St. Joseph’s Health Centre and the Volunteer Services Department as outlined during orientation and training.

I understand that SJHC is committed to protecting the privacy of my personal information in its possession. Personal information in SJHC’s possession will be kept confidential and it will not be sold, traded or loaned to any other organization. The information on this form will be used by SJHC to identify volunteer interest and determine suitability for a specific volunteer position. The volunteer/SJHC relationship can end at any time by either party (this relationship is at will and is not a contract of employment).

Question - Not Required - Name:

Question - Not Required - Date:

Month

Day

Year

*If you are under the age 18 please obtain parental or legal guardian consent

Question - Not Required - Parent's name:

Question - Not Required - Parent's phone: