APPLICATION FORM

Type your answers in the fields provided. This form must be mailed or delivered with accompanying documents.

Handwritten or incomplete applications, faxes and e-mails will NOT be accepted.

Please check one only: [ ] STUDENT ACHIEVEMENT AWARD[ ] PEGGY TEMPLE AWARD

Name:

Address:

Telephone #(s):

Email Address:

Gender: Male [ ] Female [ ]

EDUCATION BACKGROUND

Presently Attending:[ ] Secondary School [ ] College [ ] University

Name of institution currently attending:

Current grade or level:

Education plan for next year:[ ] College[ ] University

[ ] Alternate Training (please describe):

Name of institution you plan to attend next year:

Field of study and career goal:

VOLUNTEER SERVICE

Using the charts below, list your experience in each of the followingthree volunteer categories.

Notes: Example of how to calculate total hours: 2 hrs/wk x 30 wks/yr x 4yrs = 240 hrs.

Tab the last column for additional rows to record your volunteer activity.

Check (√) the applicable column for: Initiator (I), Leader (L) or Participant (P)

IMPORTANT: Specific conformation of these activities must be included in letters of support.

1. MACKENZIE HEALTH STUDENT VOLUNTEER (Include shifts and hospital fundraising activity)
Activity / Position / Explanation: What did you do / Start & End Dates / Total Hours / I / L / P
1. MACKENZIE HEALTH STUDENT VOLUNTEER (continued)
Activity / Position / Explanation: What did you do / Start & End Dates / Total Hours / I / L / P
2. SCHOOL ACTIVITIES (i.e. clubs, committees, fundraisers, peer tutoring, school council, teaching assistant, etc.)
Activity / Position / Explanation: What did you do / Start & End Dates / Total Hours / I / L / P
3. COMMUNITY INVOLVEMENT(i.e. religious/social work, canvassing for politicians, fundraisers, coaching, etc.)
Activity / Position / Explanation: What did you do / Start & End Dates / Total Hours / I / L / P
4. VOLUNTEER SERVICE AWARDS (if applicable)
Award Date / Description of Award
  1. Which of your volunteer experiences have you found the most satisfying and why?

Please limit youranswer to 200 words.

  1. What influence do you think your volunteer experience will have on your intended vocation? Please limit your answer to 200 words.
  1. What additional personal information do you wish to share in consideration of this award?

Please do not exceed 200 words.

______

VERIFICATION

I hereby certify that the above information is correct and can be verified on request.

Signature of ApplicantDate

IMPORTANT REMINDERS:

It is YOUR responsibility to provide individuals who are supplying letter of support with an overview of your application to ensure their letters confirm and substantiate the volunteer activities you have listed.

  • Letters of support must:
  1. Include comment on your application in light of the Selection Criteria
  2. Confirm and support your stated volunteer activities
  3. Be included with the application form in separate sealed envelopes
  • Recommendation letters from fellow student volunteers, friends and relatives are NOT acceptable. If a fellow student volunteer is your supervisor, an alternate Mackenzie Health reference is required.
  • Recommendation letters that deal solely with your academic abilities or performance as an employee, and character references of a general nature do NOT qualify.
  • Handwritten or incomplete application packages, faxes and e-mails will NOT be accepted.

HAVE YOU INCLUDED:

[ ]Completed Application form. Application forms must be typed and mailed or hand-delivered in a single envelope along with the followingsupport documents.

[ ]Three letters of support– one from each of the required volunteer categories:

  1. Mackenzie Health volunteer shift supervisor
  2. School principal, teacher or guidance counselor
  3. Community representative, religious leader or event organizer

[ ]An acceptance form or registration form from a post-secondary institution, indicating acceptance into a grogram or current registration in a program.

SUBMIT COMPLETED APPLICATION PACKAGES TO:

Volunteer & Community Resources – Room #2934B-Wing

Mackenzie Health

10 Trench Street

Richmond Hill, ON L4C 4Z3

Submission Deadline: Monday, April 30th, 2018 @ 4:00 p.m.

Application forms and supporting documents will not be returned.

Please make a copy of your application package for your records.