Volunteer Application

Contact Information

Full Name*:	Required
Home*:	Required
Work:
Cell:
Street Address*:	Required
City/Town*:	Required
Province*:	Required
Postal Code*:	Required
Email Address:

Location

Your Location Preference*:

Select one No Preference Cardston – Lee Crest Edmonton – Southgate Care Centre Edmonton – Good Samaritan Place Edmonton – Dr. Gerald Zetter Care Centre Edmonton – Wedman House & Wedman Village Edmonton – Mill Woods Centre Edmonton – Seniors’ Clinic Evansburg – Pembina Village Gibsons – Christenson Village Hinton – Mountain View Centre Kelowna – Mountainview Village Lacombe – Royal Oak Manor Lethbridge – West Highland Centre & West Highland Estates Lethbridge – Park Meadows Village Magrath – Garden Vista Medicine Hat – South Ridge Village Nanaimo – Wexford Creek New Westminster – Victoria Heights Penticton – Village by the Station Pincher Creek – Vista Village Raymond – Prairie Ridge Rocky Mountain House – Clearwater Centre Salmon Arm – Hillside Village Spruce Grove – Spruce Grove Centre Stony Plain – Stony Plain Care Centre Stony Plain – George Hennig Place Vernon – Heron Grove Wetaskiwin – Good Shepherd Home Required

Are there specific geographic areas you are interested in (i.e. South East Edmonton)?

References (no family members)

1)	Name*:	Required	2)	Name*:	Required
	Relationship*:	Required		Relationship*:	Required
	Phone*:	Required		Phone*:	Required
	Email*:			Email*:

Current Status

Select a status*: -- select one -- Student Employed Full Time Employed Part Time Homemaker Retired Unemployed Visitor to Canada Select One (Required)

Education, Skills, Interests

Present/Former Occupation:
Educational Background:

Languages Spoken:

Hobbies, Interests, Skills:

Background

Describe any previous paid work experience:

Describe any previous volunteer experience:

Are there any health problems or physical limitations you have that may affect your volunteer work?

Do you have a criminal record?* Required

Yes No

Client Interest

Is there a particular type of volunteer work in which you are interested?*
(Check all that apply)

Select One (Required)
Working one-on-one with a single client
Working directly with a staff person
Working in a group environment
No Preference

Is there a person or group with whom you are particularly interest in working with?*
(Check all that apply)

Select One (Required)
Mentally Challenged
Respiratory Conditions
Physically Challenged
Dementia
No Preference

Availability Frequency*

Select One (Required)
25 hours (short term) more than 25 hours (long term) once per week
twice per week other

Number of hours per day* Required

Select One (Required)	Morning	Afternoon	Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Transportation

Do you have access to a car?*

Required
Yes No Occasionally

I give permission to The Good Samaritan Society to obtain information regarding my previous employment, education and/or volunteer background.* Required

Yes No