Student Placement Application

At Lanark County Interval House and Community Support, we believe every woman and child should live with dignity and be free from threatening situations. To accomplish our goals of protecting these women and children, we rely heavily on the help of our volunteers and students. We greatly appreciate your willingness to assist LCIHCS and will strive to provide you with a rewarding educational experience.

To complete a student placement with LCIHCS, please submit your application form including two references and your proof of full vaccination. If you have a valid police record check within the past three years, please attach this document as well. LCIHCS will interview you at your convenience and provide you with a letter for a police criminal record check if required.

Please be advised: If you have been abused by an intimate partner, LCIHCS recommends volunteers free from the relationship for at least two years and receive counselling prior to beginning your role with us. Any questions or concerns may be addressed to the Volunteer Coordinator. LCIHCS does not guarantee a student placement to all applicants.

Name*

Date*

Date

Phone*

Alternate Phone

Email*

example@example.com

Preferred Contact Method*

Mailing Address*

Emergency Contact Name*

Phone*

Please indicate any medical or health concerns we should be aware of that may affect your ability to perform volunteer tasks and/or require accommodations such as challenges in accessibility, mental health, physical health, allergies, etc.:*

Do you have a valid driver's license?*

YesNo

I understand this placement is located in Carleton Place, ON and have access to reliable transportation.*

YesNo

Do you have a valid CPR Training?*

YesNo

What language(s) do you speak/write?*

I give LCIHCS permission to use my name and photograph on social media and printed publications*

YesNo

I understand that I must provide proof of full vaccination against COVID-19*

YesNo

I understand that I must provide a valid Vulnerable Sector Check and will obtain one should I not have a valid check*

YesNo

School*

Program of Study*

Placement Coordinator/School Contact Name*

Phone*

Email*

example@example.com

Desired Placement Start Date*

Date

Required Placement Duration*

What are your expectations and/or needs in terms of support and supervision?*

Why do you want to complete your placement at Lanark County Interval House?*

Aside from your program, please indicate any relevant training, skills or interests*

LCIHCS works from a feminist perspective. What does this mean for you?*

Name*

Phone Number*

Email*

example@example.com

Relationship to You*

Name*

Phone Number*

Email*

example@example.com

Relationship to You*

By signing and submitting this Volunteer Application, I acknowledge this information is true and accurate. I authorize Lanark County Interval House and Community Support to obtain references from the individuals listed above. I understand that any misrepresentations will be grounds for termination of my student placement.

Signature*

Date*

Date

Signature of Legal Guardian if under 18

Date

Thank you for taking the time to fill out this volunteer application. If you have any questions, comments or concerns please contact our Volunteer Coordinator at (613) 257-3469 ext. 63 or email

Student Placement Application Form

Placement Information

References

REFERENCE 1:

REFERENCE 2: