Espanola Regional Hospital and Health Centre

About Espanola Regional Hospital and Health Centre

Volunteer Application Form Thank you for your interest in pursuing a volunteer opportunity at the Espanola Regional Hospital &Health Centre. Please complete this form and return it to the Volunteer Engagement Department. Volunteer Engagement Department Tel: (705) 869-1420 ext. 3074 Espanola Regional Hospital & Health Centre 825 McKinnon Dr. Espanola Ontario, P5E 1R4 [email removed] PERSONAL INFORMATION Name: Address: City: Postal Code: Home Telephone: Other Telephone: Email Address: Date of Birth: Note: All applicants must be 14 years of age or older. Month / Day / Year Gender: Language(s) Spoken: Health Restrictions / Limitations: How did you find out about our volunteer program? Referral Event Website School Facebook Newspaper Radio Are you currently an inpatient at the Espanola Regional Hospital & Health Centre? Yes No Note: To ensure that quality patient care remains a priority at the Espanola Regional Hospital & Health Centre, volunteer applications will not be accepted from inpatients. EMERGENCY CONTACT INFORMATION Name: Relationship: Telephone: Family Physician: Telephone: ADDITIONAL INFORMATION Educational Background: High School Diploma College Diploma Field of Study: Undergraduate Degree Field of Study: Post-Graduate Degree Field of Study: Professional Designation Field of Study: Certification Field of Study: For High School Students Only: Grade Name of School Name of Homeroom Teacher Professional / Work Experience: Special Interests, Skills and Hobbies: Community / Volunteer Experience: I am interested in volunteering at the following Espanola Regional Hospital & Health Centre location: Espanola Regional Hospital Espanola Nursing Home Foundation I am interested in the following area(s): General / Public Acute Care I will commit to volunteering for: Six Months More than Six months Note: We also consider summer students who are available to volunteer for 2-3 months. I am available to volunteer: Time \ Day Mon Tues Wed Thurs Fri Sat Sun Morning Afternoon Evening I like to take extended vacations during: Summer months Winter months VOLUNTEER AGREEMENT 1. If I am accepted for a volunteer position, I agree to comply with the guidelines of the volunteer position and will adhere to the policies and procedures of the Espanola Regional Hospital & Health Centre and Volunteer Engagement Department. 2. I understand that the volunteer uniform and photo ID card are the property of the Espanola Regional Hospital & Health Centre and must be worn at all times when volunteering in the hospital. Upon termination as a volunteer, I will immediately return the aforementioned items to the Volunteer Engagement Department. 3. I agree to my photograph being taken for identification and/or media purposes. 4. I confirm that the information provided in this application is accurate, and I authorize investigation of all statements made in this application. Signature of Applicant Date

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Company Type: Hospital

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