First Name * Last Name * Address * City * Province * Postal Code* Country * Home Phone # (555-555-5555) * Cell # Business # E-mail Address * Re-type e-mail address * Main intersection closest to your home. Emergency Contact Information: Name: Phone: Relationship: Why does volunteering at VHA Home Healthcare appeal to you? Please indicate your availability. Monday Morning Afternoon Evening Tuesday Morning Afternoon Evening Wednesday Morning Afternoon Evening Thursday Morning Afternoon Evening Friday Morning Afternoon Evening Saturday Morning Afternoon Evening Sunday Morning Afternoon Evening Please indicate any extended periods during the year when you are unable to volunteer: Anything else you want to tell us about your availability? EDUCATION Please indicate your highest level of education -- ChooseOne -- Some High School High School Diploma Certification Some College College Diploma Some University Undergraduate Degree Masters or higher Area(s) of Specialization Additional Courses, Seminars, Workshops, Skills, Experience, Training EMPLOYMENT/ VOLUNTEER EXPERIENCE Employer Name Employment Dates From (mm/yyyy): To (mm/yyyy): Position Duties and Responsibilities Supervisor's Name and Title Contact Information (telephone # and/ or email address) VHA Home HealthCare is authorized to obtain a reference from the above employer Yes No Employer Name Employment Dates From (mm/yyyy): To (mm/yyyy): Duties and Responsibilities Supervisor's Name and Title Contact Information (telephone # and/ or email address) VHA Home HealthCare is authorized to obtain a reference from the above employer Yes No Employer Name Employment Dates From (mm/yyyy): To (mm/yyyy): Duties and Responsibilities Supervisor's Name and Title Contact Information (telephone # and/ or email address) VHA Home HealthCare is authorized to obtain a reference from the above employer Yes No Employer Name Employment Dates From (mm/yyyy): To (mm/yyyy): Duties and Responsibilities Supervisor's Name and Title Contact Information (telephone # and/ or email address) VHA Home HealthCare is authorized to obtain a reference from the above employer Yes No Where did you hear about this volunteer opportunity? -- Choose One -- VHA Website From materials displayed in my community Volunteer Centre Volunteer/ Job Fair A Friend/ Colleague approached me Charity Village Other Volunteer Confidentiality Agreement: At all times the privacy and dignity of clients, volunteers and staff will be respected, and the mission, vision and philosophy of VHA Home Healthcare will be followed in accordance with the organization’s policies, standards and guidelines. All client information will be treated as confidential material. Volunteers shall not discuss client interactions with people outside the VHA organization, including family members and friends. By checking 'I agree' I acknowledge that the information provided is true and accurate, and that I have read, understand, and will abide by the agreement above. * I agree Only authorized VHA Home Healthcare staff access this information .This information will be stored in a locked cabinet and if you become a volunteer it will be entered into our secure data base to track your volunteer activities and hours.