Are you a student? Are you an adult?

Have you previously worked or volunteered at the Brantford General or Willet Sites? Yes- No-

If yes, where?

Present Occupation:
Full Time? Part Time?

Previous Volunteer Experience:

What are your interests, hobbies or skills?

Where do you want to volunteer? BGH Willett

How did you hear about volunteering at the BCHS?
Word of Mouth Internet Walk-in Media Work School
If other, please let us know:

Why are you interested in volunteering?
Spare time School Community Involvement Hours Interaction with people Community Involvement
Interest in health career Course
If other, please let us know:

Days/Times available:

Do you have any physical limitations to your activities? (lifting, pushing wheelchairs, other)

Have you ever been convicted of a criminal offence for which a pardon has not been granted?

Yes No

It is the responsibility of the Hospital to protect its patients and staff from any disease or infection which might be brought in by new volunteers. for this reason all new volunteers must, as a condition of volunteer placement, receive a passing health review as required by the Hospital, in accordancew the Public Hospitals Act and other legislative acts. Repeat examinations as required by legislation ot the Hospital are mandatory.

Would you consent to a Health Review? Yes No

PERSONAL REFERENCE:

BUSINESS REFERENCE

Through the act of submitting this form, I hereby authorize the Brant Community Healthcare System to contact any of my present or previous employers/volunteer placements/references to make any inquiries usually required to determine my suitability for volunteer placement.

Every effort will be made to place you as soon as possible. There may be a delay until a mutually satisfactory position becomes available. Orientation and training will take place when you are assigned to a position.