CCSS Volunteer Application Form – Connections Community Services Society

1Personal Information

Legal First Name*

Legal Last Name*

Preferred Name

Date of Birth

Primary Contact Number*

Format: (123) 456-7890

E-mail*

ex: myname@example.com

Address

City

Postal Code

Main Language

Other Language(s)

Education Level

School

Grade

Length in Canada (Years)

Country of Origin

How did you learn about us?

2Emergency Contact

First Name

Last Name

Emergency Contact Number

Relationship to you

Main Language

3Availability & Skills

Availability (check all that apply)

Time	Mon	Tue	Wed	Thu	Fri	Sat	Sun

Please upload a copy of your resume (PDF/DOC/DOCX/image, max 10 MB)

Which programs / support are you interested in volunteering for?

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Skills

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Other Area of Interests / Talents / Additional Information

Desired length of commitment

4Medical Conditions

Do you have any medical conditions?

Yes No

Do you have any food allergies or specific dietary needs?

Yes No

5Statement of Purpose

What makes you interested in becoming a volunteer?

What draws you to our specific organization and/or projects?

What are your career goals as a volunteer?

Can you describe what volunteering means to you?

Can you tell us a fun fact about you?

6Self-Disclosure of Criminal Background

Have you been convicted of a crime (including felonies and misdemeanours)?

Yes No

Have you ever been investigated for child or dependent-adult abuse or neglect?

Yes No

Required Additional Information (if either answer is YES, please explain)

Are you willing to provide your Criminal Record Check if required?

Yes No

7Waiver of Liability and Photo Consent

You must agree to the first two acknowledgements to volunteer. Photo consent is optional.

*I understand, acknowledge and agree that I must assume the risk and any related financial responsibility that could result from participation in any of the activities provided by the Connections Community Services Society (CCSS). *I understand that CCSS is not responsible for providing or administering medication to me. I agree to make arrangements for myself to have all necessary medications that I need and the means to take them when required. In case of sickness or accident, CCSS has my approval to secure such medical attention as deemed necessary, if my emergency contact person is unable to be contacted. I further understand that neither CCSS nor any of its paid or volunteer workers can be held responsible in the event of accident or accidental death. I give permission to CCSS to take pictures of myself for promotional materials, website images, or reports developed by the agency. CCSS respects the rights and privacy of volunteers and participants and will delete any photos of the volunteer or participant upon request. (Optional)

8Signature

Please sign below*

9Parental/Guardian Consent

Shown and required when the applicant is 18 or younger (based on Date of Birth).

I, the parent/guardian named below, hereby authorize my child (the applicant named above) to participate in program activities of Connections Community Services Society (CCSS).

* I understand that CCSS is not responsible for providing or administering medication to my child. I agree to make arrangements for his/her needs and the means to take them when required. In case of sickness or accident, CCSS has my approval to secure such medical attention as deemed necessary, if the emergency contact person is unable to be contacted. I further understand that neither CCSS nor any of its paid or volunteer workers can be held responsible in the event of accident or accidental death. * I understand that participation at CCSS activities might involve travelling with CCSS staff and coming into close contact with the public. I give permission to CCSS to take pictures of my child for promotional materials, website images, or reports developed by the agency. CCSS respects the rights and privacy of volunteers and participants and will delete any photos of the volunteer or participant upon request. (Optional)

By signing this form, I am stating and confirming that I am his/her legal parent/guardian and that:

* I have provided accurate information, disclosed all relevant medical details and any other information that may impact the participation and supervision required for my child. * I have fully read the form and its requirements, and I HEREBY RELEASE AND FOREVER DISCHARGE Connections Community Services Society, its employees, directors, and agents, of and from all manner of actions, causes of action, claims and demands of whatsoever nature which my child may have in respect of any injury, loss or expenses he/she may sustain arising from or in any way connected with his/her participation in the program.

Name of the Parent/Guardian (First)*

Name of the Parent/Guardian (Last)*

Parent/Guardian Signature*