Mr Ms Mrs Miss Other ______Preferred First Name: ______

Last Name: ______First Name: ______

Address: ______

City:______Postal Code: |___|___|___| |___|___|___|

Telephone: Home: (____) ______Business: (____) ______Cell: (____) ______

Pager: (____) ______E-Mail: ______

Citizenship: Canadian Other: ______Age Group: Under 19 Over 19 ______

Why are you interested in volunteering for us? ______

______

What type of Auxiliary activities interest you? ______

______

Can you volunteer on a regular basis? No Yes, what times are you available for volunteer work?

Please indicate blocks of specific times in the spaces provided:

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
AM
PM
EVE

Would the times be regular, or would they need to change frequently? Regular Change

If your hours would change frequently, please explain: ______

List any hobbies/skills/interests/experiences: ______

______

Do you speak and/or write languages other than English: No Yes

If YES, please specify: ______

Continued on back page…

Office Use Only:

Rec’d Date:

/

On Hold Date:

Comments / Notes:

Return completed applications to: Peace Arch Hospital Auxiliary Society 15521 Russell Avenue, White Rock, BC V4B 2R4 Phone: 604-535-4500 757680 Fax: 604-541-5805 Email: auxiliary.

VOLUNTEER: Are you presently a volunteer? No Yes

If yes, where: ______How long? ______

Have you volunteered previously for an Auxiliary? No Yes, when/where: ______

Describe any previous volunteer experience: ______

______

EMPLOYMENT: Are you currently employed: Yes No Full Time Part Time Casual

Current Employer: _________

May we contact you at work: Yes No

Previous Employment: (attach resume if you wish) ______

______

EDUCATION/TRAINING: If you are currently a student, what school/university do you attend:

______

Area of Study: ______Year/Grade: ______

List any past relevant education/training you have: ______

Group Activities Gift Shop Gift Cart

Superfluity Shop Executive Positions Special Events Other

______

A current criminal records check is required upon approval to volunteer as a member of the Peace Arch Hospital Auxiliary Society. Volunteers will be given the necessary paper work to be presented at your local RCMP office.

Please provide two references (not relatives) that have known you for at least 6 months; one personal, and one business or volunteer related: (Please inform your references they will be contacted)

Name: ______Phone: (___) ______

Personal Relationship to you: ______Email: ______

Name: ______Phone: (___) ______

Business/Volunteer Relationship to you: ______Email: ______

Emergency Information: In case of emergency, contact Name: ______

Telephone: Home: (___) ______Business: (___) ______Cell: (___) ______

** Please read the following carefully before signing this application **

“I ______(Print your name) confirm that the information in this volunteer application is complete and true. I understand and agree that any omission or misrepresentation with respect to the information given may be cause for refusal of volunteer placement, or if I am a volunteer of PAHAS may be cause for immediate termination.

I understand that a Criminal Record Check is required. I authorize PAHAS to contact the references listed and give permission to these references to release all relevant information requested. I understand that an annual membership fee is required.

I understand, and give permission for PAHAS to keep a record of my personal information and that it will remain confidential to PAHAS and Volunteer Resources. I understand that this information may be disclosed to any party with legal and proper interest, and I release the agency from any liability whatsoever for supplying such information.

Signature: ______ Date ______