Revised: August 2014 Page 1 of 2

The personal information on this form is held in strict confidence and is used to assess the suitability of your skills and experience with the volunteer position being advertised. Your information may also be used to collect data and maybe shared internally order to coordinate volunteer activities with other volunteers or staff. Any questions about the collection of this information should be directed to Katie Haneke, Registered Dietitian and CFE Program Lead, Grand River Community Health Centre, 363 Colborne St. Brantford ON, N3S 3N2,
tel. 519-754-0777x234 fax 519-754-0757 or
Applicant information
Last name: / First name:
Today’s date: / Phone:
Address:
City: / Province: / Postal code:
E-mail address:
Background information
1. What skills or experiences have you had working with people (as a volunteer, on the job, in a community group, professional association)? Describe any leadership positions you have held.
2. Why do you want to become a Community Food Educator and what do you hope to achieve in the role?
3. Describe any previous training you have had relating to healthy eating and safe food handling (what, when, and where).
4. Describe any experiences you have had speaking in public (including teaching, presenting or facilitating).
9. Language(s) spoken, if other than English:
10. Times you would be generally available for participating in volunteer service and ongoing training:
Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
Morning
Afternoon
Evening
11. Dates that you know you would not be available for training, service or meetings (work, school, vacation, family commitments, etc.).
12. Is there anything else you would like to tell us that relates to you becoming a Community Food Educator?
References
Please provide the names of two persons (preferably one professional reference and one character reference) who would be willing to provide a reference on your behalf.
Name: / Name:
Address: / Address:
Occupation: / Occupation:
Phone: / Phone:
I ______give my permission for Grand River Community Health Centre to contact the above two references.
I hereby declare that the foregoing information is true and complete to my knowledge. I understand that a false statement may disqualify me from volunteering with Grand River Community Health Centre or cause my dismissal.
Signature: / Date:
Emergency contact
Name: / Relationship: / Phone:
Application return information
Thank you for your interest in Grand River Community Health Centre. We will respond by phone or email to those chosen for an interview.
Please return or email the application to:
Katie Haneke, Volunteer Coordinator
Attn: CFE Program
363 Colborne Street, Brantford ON, N3S 4N2
Phone: 519-754-0777, x. 234
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Revised: August 2014 Page 1 of 2