Volunteer Form

Volunteer/ Convener/ Instructor Application Form

Eganville and District Seniors
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Alternate Number

Area CodePhone Number
E-mail
Date of Birth*

MonthDayYear
Gender

MaleFemaleOther
Emergency Contact*

First NameLast Name
Emergency Contact Phone*

Area CodePhone Number
Please indicate the areas you wish to volunteer in*

TransportationTelephone AssuranceMeals on WheelsVolunteer DriverHome MaintenanceTax ServicesOther
Are you a smoker?*

YesNo
Medical Limitations that could affect this voluntary position?*

YesNo
If yes, please explain
Have you ever been convicted of a criminal offence?*

YesNo
If yes, please explain
2 References: Name and phone number (non-relatives only)*
How did you find out about our organization?*
Why do you want to volunteer?*
Hours available per month?*
When available:*
a.m.-p.m.
Past work experience:*
Experience with seniors:*
I give the Eganville and District Seniors Citizens' Needs Association permission to contact the above refrences and/ or the Minstiry of Transportation to verify my suitability for a volunteer position.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Volunteer/ Convener/ Instructor Application Form