CRISIS RESPONDER APPLICATION
THIS APPLICATION WILL BE KEPT ON FILE FOR A MAXIMUM OF TWELVE (12) MONTHS ONLY
NAME : _____________________________________________________________________
ADDRESS: _____________________________________________________________________
____________________________ Postal Code______________________________
TELEPHONE: (HOME) ______________________ (OTHER)________________________________
EMAIL ADDRESS: ___________________________________________________________________
ARE YOU OVER THE AGE OF TWENTY-ONE (21)? YES NO
DO YOU HAVE ACCESS TO AN AUTOMOBILE? YES NO
OUR VOLUNTEERS MUST MAINTAIN $1 000 000.00 LIABILITY INSURANCE ON THEIR VEHICLES. DO YOU HAVE ADEQUATE COVERAGE? YES NO
WOULD YOU OBJECT TO A CRIMINAL REFERENCE CHECK? YES NO
IF YES, WHY? ________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENCE OF WHICH A PARDON HAS BEEN GRANTED? YES NO
HAVE YOU HAD ANY CONTACT WITH THE POLICE THAT WOULD NEGATIVELY IMPACT YOUR ROLE AS A VOLUNTEER? YES NO
IF YES, HOW? _________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
OTHER TRAINING WHICH MAY BE RELEVANT (CPR,WORKSHOPS,APPRENTICES, ETC.)_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PRESENT VOLUNTEER EXPERIENCE: _____________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
INTERESTS, SKILLS, HOBBIES: ____________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
WHY ARE YOU INTERESTED IN BECOMING A VOLUNTEER WITH VICTIM SERVICES ELGIN?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HOW DID YOU HEAR ABOUT VICTIM SERVICES ELGIN? __________________________________
______________________________________________________________________________________
I ACKNOWLEDGE THAT THIS APPLICATION AND ALL OTHER RELATED FILE INFORMATION COLLECTED IS THE PROPERTY OF VICTIM SERVICES ELGIN.
SIGNATURE: ____________________________________________________________
DATE: ____________________________________________________________
ALL INFORMATION CONTAINED HEREIN WILL BE STRICTLY CONFIDENTIAL
PLEASE PROVIDE TWO REFERENCES: (other than family members e.g. employer, clergy, teacher)
NAME: ____________________________________RELATIONSHIP___________________________
ADDRESS: ________________________________________________________________________
TELEPHONE DAYTIME: ___________________________ EVENING: __________________________
NAME: ____________________________________RELATIONSHIP___________________________
ADDRESS: ________________________________________________________________________
TELEPHONE DAYTIME: ___________________________ EVENING: __________________________
IN MAKING THIS APPLICATION, I GIVE PERMISSION TO VICTIM SERVICES ELGIN TO CONTACT THE PERSONS NAMED AS REFERENCES TO ASCERTAIN MY SUITABILITY AS A VOLUNTEER.
SIGNATURE: ____________________________________DATE:_____________________________
PLEASE RETURN YOUR COMPLETED APPLICATION TO:
Victim Services Elgin
146 Centre Street,
ST. THOMAS, ON
N5R 3A3