Volunteer Registration – Simcoe Hall Settlement House

Name

Home Address

City

Postal Code

Phone

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?

Yes No

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?

Yes No

If no, are you willing to obtain one?

Yes No I already have one

Have you completed First Aid and CPR/AED training or similar training?

Yes No

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 INFORMATION

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?

If a volunteer opportunity is not available for you at this time, can we contact you at a later date?

Yes No

Reference Information Provide name and phone number of at least 2 references that we can call:

Reference #1

Reference #2

VOLUNTEER AND STUDENT CONFIDENTIALITY POLICY

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 agree I do NOT agree

STUDENT PLACEMENT AND VOLUNTEER CONSENT AND HOLD HARMLESS AGREEMENT

"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 agree I do NOT agree

Volunteer WITH US