Volunteer Registration Form – Perth and Smiths Falls District Hospital

Volunteer Registration Form – Perth and Smiths Falls District Hospital

Register to become a valued volunteer at the Perth and Smiths Falls District Hospital. Please complete all sections to help us match your interests, availability, and preferences to our volunteer opportunities.
Personal Information

Please provide your contact details so we can reach you regarding your volunteer application.
First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2
CityProvincePostal Code
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Emergency Contact Information

In case of emergency, please provide details of a contact person.
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Site Preference

Please select your preferred volunteer site.
Preferred Site*

Smiths Falls SiteGWM (Perth) SiteNo Preference
Areas of Interest

Select the areas you are interested in volunteering and note which sites they apply to.
Please select all areas you are interested in:*

Meal Assistance (Both Sites)Information Desk (Both Sites)Gift Shop (Smiths Falls Site)Gift Shop (GWM (Perth) Site)Tea and Toast (Smiths Falls Site)Clinics (Both Sites)Portering (Both Sites)Crafts (Both Sites)Executive Roles (Both Sites)Public Relations (Both Sites)Communication Committee (Both Sites)Friendly Visiting (Both Sites)Other
Availability

Indicate your availability for each day and shift.
Monday Availability

MorningAfternoonEvening
Tuesday Availability

MorningAfternoonEvening
Wednesday Availability

MorningAfternoonEvening
Thursday Availability

MorningAfternoonEvening
Friday Availability

MorningAfternoonEvening
Saturday Availability

MorningAfternoonEvening
Sunday Availability

MorningAfternoonEvening
Auxiliary Annual Fee Acknowledgment

Please acknowledge the annual fee for each auxiliary. Fees are payable upon acceptance as a volunteer.
I acknowledge the annual fee for the auxiliary I join:*

Smiths Falls Community Hospital Auxiliary – $5.00 per yearGreat War Memorial Hospital Auxiliary (Perth) – $10.00 per year
Commitment and Consent

Please review the following commitments and provide your consent.
Please confirm and agree to the following:*

I agree to share my contact information with the Auxiliary and Hospital as needed.I confirm that I am at least 16 years of age.I agree to return my ID badge and uniform upon leaving the volunteer program.
Signature (Type your full name to sign)*
Date of Signature*

MonthDayYear
Date
Should be Empty:

Volunteer Registration Form – Perth and Smiths Falls District Hospital

Personal Information

Emergency Contact Information

Site Preference

Areas of Interest

Availability

Auxiliary Annual Fee Acknowledgment

Commitment and Consent