Name
Home Address
City
Postal Code
Phone
Email
Your Age Category Youth (14-18)Adult (19-65)Senior (65+)
Is your interest in volunteering part of your required 40 hours of Community Service for your high school graduation? YesNo
If yes, which high school do you attend?
Some of the Simcoe Hall Settlement House volunteers are required to do a Vulnerable Sector Police Check. Do you currently have a valid Vulnerable Sector Check? YesNo
If no, are you willing to obtain one? YesNoI have one
Have you completed First Aid and CPR/AED training or similar training? YesNo
Do you have any health restrictions, conditions or medications that we should be aware of to ensure your comfort or safety? If so, please provide details below:
Emergency Contact Name:
Emergency Contact Phone Number:
Please explain why you would like to volunteer with Simcoe Hall:
Please provide the days, times and frequency that you are able to volunteer below:
Please list any special skills, interests, hobbies or knowledge that you bring to Simcoe Hall:
What is/are your areas of interest? Food Bank ServicesSeniors Lunch & Leisure ProgramsChristmas Food & Toy DriveChildren’s After School ProgramSpecial Event & Fund RaisingRepairs
Please provide the name and telephone number of at least two references:
If a volunteer opportunity is not available for you at this time, can we contact you at a later date? YesNo
Staff, student placements and volunteers of Simcoe Hall Settlement House may receive, view or hear confidential information. The protection of our clients / members right to privacy and confidentiality is critical and must be maintained by all Simcoe Hall Settlement House employees, directors, volunteers and students placements. “Confidential Information” means information, in any form, that if disclosed to a third Party outside of Simcoe Hall, or discussed in a public venue, may cause harm to a client, member or to Simcoe Hall Settlement House itself. Confidential information also includes any personal identifying information such as a name, address, telephone number, date of birth or personal circumstances. If an employee, director, volunteer or student placement has any doubt as to whether or not certain information is confidential, he/she must seek and obtain direction from a supervisor or director. Confidential information cannot be disclosed without the written and informed consent of the person it pertains to. A breach of confidentiality can result in suspension or dismissal. I agreeI do NOT agree
“I AGREE TO INDEMNIFY AND HOLD HARMLESS Simcoe Hall Settlement House, its agents, employees or volunteers of all liability for loss or damage arising from any cause whatsoever and hereby release, waive and discharge Simcoe Hall Settlement House from all liability to my heirs, executors, administrators and assigns for all loss or damage and any claims or demands for such loss or damage on account of injury to person or property while participating in and/or being transported to and from the program activities of Simcoe Hall Settlement House. I agreeI do NOT agree
"I Hereby give permission to Simcoe Hall Settlement House to provide or arrange for such first aid or other medical treatment or care, including but not limited to transportation to hospital, as such staff may consider necessary or advisable. I understand that all costs related to such actions shall be my responsibility and I agree to pay for and/or reimburse Simcoe Hall Settlement House for any such costs that may be incurred. I accept full responsibility for ensuring that I am physically and medically fit to participate in the programs and activities of Simcoe Hall Settlement House throughout the duration of my field placement or volunteer service." I agreeI do NOT agree
