This form is also available to be filled out electronically at

For further information, please contact us at 1-877-268-2211, or via email at

Thank you for your interest in volunteering with the Upper Canada Chapter of Autism Ontario.

Our chapter would not exist without the support of volunteers.

Our chapter serves families in Cornwall and the following counties: Stormont, Dundas, Glengarry, Leeds, and Grenville.

Please fill in the info in the text boxes, “save as” Volunteer_Application_yoursurname and email to Please mail a signed copy to:

Volunteer Recruitment Team

Autism Ontario

Upper Canada Chapter

P.O. Box 343

Cornwall, ON

K6H 5T1

Section A – Contact Information

Name:County:

Address:

City:Province:Postal Code:

Phone (day):Phone (other):

Email:

Would you like to be added to our email distribution list to receive news and updates from Autism Ontario and Upper Canada Chapter? Your email and personal information will not be shared with any other organization.

YesNo

In case of emergency, please contact:

Name:Phone:

Section B – Getting to Know You

  1. How did you hear about Autism Ontario?
  1. Why are you interested in volunteering with Autism Ontario?
  1. What would you like to contribute as a volunteer at Autism Ontario?
  1. What would you like to gain from your volunteer experience?
  1. Are you presently a volunteer with another organization?If yes, please specify the organization, role, and length. of time
  2. What work/volunteer experience have you had that you think might be useful?
  1. Do you have language skills in a language other than English?

Speak:Read:Write:

Section C – Availability

When would you usually be available to volunteer:

DaysMorningsAfternoonsEvenings

Days of the week you are usually available to volunteer:

Mon.Tues.Wed.Thurs.Fri.Sat.Sun

How much advance notice would you need to volunteer?

a few daysa weekmore than a week

Section D – References

Name:Relationship:

Phone:Phone (alternate):

Name:Relationship:

Phone:Phone (alternate):

Section E – Permission and Release

  1. The references I listed may be contacted for the purpose of processing my application to become a volunteer with Autism Ontario. I understand that these references will be contacted in confidence;
  2. I am in no way obligated to perform any volunteer services for Autism Ontario;
  3. I understand that I may be required to undergo a Vulnerable Sector Screening check, if the position involves working with vulnerable individuals;
  4. I acknowledge and accept that this application does not guarantee acceptance to a volunteer role, and that Autism Ontario is under no obligation to accept me as a volunteer, and is not obliged to provide a reason;
  5. I hereby release and forever discharge Autism Ontario, and their employees, directors, volunteers and contract staff from any cause or claim for damages, whether bodily injury, death, property damage, or emotional trauma, anxiety or distress arising from my association with Autism Ontario.
  6. I give permission to Autism Ontario to share any information that I’ve given them, pertinent to my application to volunteer, with appropriate staff and volunteers. I understand that if Autism Ontario – Upper Canada Chapter should cease operation, my file becomes property of Autism Ontario’s Provincial Office.
  7. If I am under 18 years of age at the time of my application, my parent/guardian will complete a consent form on my behalf.

Name (print):

Signature:Date:

Name of Parent/Guardian (if under 18 years):

Signature of Parent/Guardian:Date:

What can you do?

Check all of the items that apply. If completing on computer and returning via email, then highlight the item. Please note that this is not a commitment, simply an indication of your comfort level. These activities / positions do not involve contact with minors or vulnerable individuals, with the possible exception of those identified by *

__ solicit donations (cash or materials) __ organize or help with fundraising activities *

__ speak to parents (individually) __ organizeor help with information activities

__ speak to schools/community groups __ organize or help with family social activities *

__ represent chapter at events__ organize activities for siblings (SibShops)*

__ write/research grant proposals __ organize social skills group activities *

__ take good photographs __ organize parent get togethers

__ promote events __ communicate with community organizations

__ speak to the media__ communicate with local law enforcement

__ compile info on community agencies & services__ camp administration

__ check web links__ write newsletter articles

__ organize and help with chapter events__ set up displays at chapter events

__ communicate with government representatives __ participate at provincial level

__ write or produce awareness materials __ handle finances

__ Together for Autism coordinator for chapter__ resource coordinator

__ be a SEAC representative

(other – please let your imagination run free!)

What do you know about?

__ the special education system __ integration/inclusion strategies for education

__ ABA/IBI __ VB (Verbal Behaviour)

__ setting up a home-based programs __ biomedical/DAN protocol

__ nutrition __ adaptive technology

__ augmentative communication (PECS, sign language) __ speech therapy

__ auditory integration__ social skills

__ social stories__ visual schedules

__ occupational therapy __ sensory integration

__ physical therapy __ Floortime

__ respite__ funding alternatives

__ financial/estate planning issues __ post-secondary education issues

__ housing issues __ sexuality issues

__ employment issues __ (other – please specify)

Are you interested in provincial-level activities?

Opportunities to participate on provincial-level committees or consultation groups arise during the year. It is impossible to predict what kind of opportunities will arise or what kind of commitment they will require, nor is there any obligation for us to participate. The chapter reimburses travel expenses.

Yes - I’m interested in hearing about provincial-level activities.