Volunteer Form

Volunteer/ Convener/ Instructor Application Form

Eganville and District Seniors
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Alternate Number

Area Code Phone Number
E-mail
Date of Birth *

Month Day Year
Gender

Male Female Other
Emergency Contact *

First Name Last Name
Emergency Contact Phone *

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

Transportation Telephone Assurance Meals on Wheels Volunteer Driver Home Maintenance Tax Services
Are you a smoker? *

Yes No
Medical Limitations that could affect this voluntary position? *

Yes No
If yes, please explain
Have you ever been convicted of a criminal offence? *

Yes No
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 *

Clear
Date *

Month Day Year
Date
Should be Empty:

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Volunteer/ Convener/ Instructor Application Form