Windsor Regional Hospital

Volunteer Application Form

Volunteers are an integral part of Windsor Regional Hospital. Thank you for your interest in joining our team of enthusiastic and devoted volunteers, students, and staff members.

Please note, volunteer placements are not guaranteed, only those under consideration will be contacted for an interview. Your application will be kept on file for six months. Applicants must be 16 years of age or older to apply.

Preferred Campus:

How did you learn about WRH volunteer opportunities (Select One):

If WRH Staff, Volunteer or Other, please list:

Contact & Personal Information

* First Name

* Last Name

* Date of Birth

* Home Address (Street Name):

Home Address (Apt. Unit #):

* City:

* Province:

* Postal Code:

* Email:

Phone (Cell):

Phone (Home):

* Emergency Contact (First, Last):

* Phone:

* Relationship to you:

Are you covered by OHIP?

Immigration Status:

Languages Spoken (Select All):

Volunteer Information

Do you have access to a vehicle for volunteering?

I usually take extended vacations in the:

Length of Commitment (Select All):

Area of Interest - Please visit WRH website for all placement opportunities

1st Choice:

2nd Choice:

3rd Choice:

Other, please list:

Availability - Please indicate when you are available below. Note, volunteer assignments are 3-4 hour shifts, one to two days per week.

Evening and weekend volunteer opportunities are limited and may not always be available. Most volunteer support is needed on weekdays, Monday-Friday, between 8:00am-4:00pm (i.e. Mornings 8:00am-12:00pm, Afternoons 12:00pm-4:00pm, Evenings 4:00pm-8:00pm).

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

My goal for volunteering at Windsor Regional Hospital is to (select all that apply):

Help Others

Show Appreciation

Learn New Skills

Explore Career Opportunities

Keep Active

Resume Building

Physicial Limitations

Some volunteer positions may require one to sit, stand or walk for extended periods of time. Please let us know if you have any physical limitations we need to consider with respect to your desired volunteer position.

Yes, I have some limitations, list:

Volunteer/Community Experience

Please indicate the organizations, responsibilities/positions and date/length of service where you have previously volunteered or are currently volunteering.

Organization

Responsibilities

Length

1.

2.

3.

Employment History

Please indicate your current employment status.

Occupation (Past or Present):

Retired

Self Employed

Employed Full-Time

Employed Part-Time

Looking For:

Part-Time

Full-Time Employment

Currently not employed

Education Background

High School

Not Attending School

College/University - Years Completed:

1

2

3

4

Skills/Interests/Hobbies

Skills - Please select all that best describe you.

Other, list:

References

Please note: References must be completed by anyone who is not a family member. They will be contacted upon selection for an interview.

* 1. Volunteer Reference Name:

Phone:

Email:

* Relationship to You:

* 2. Volunteer Reference Name:

Phone:

Email:

* Relationship to You:

Volunteer Placement Agreement

Please read this agreement slowly and carefully to ensure full understanding before signing.

If accepted as a Windsor Regional Hospital (WRH) volunteer, I agree that:

I shall hold all confidential information that I may obtain directly or indirectly concerning clients, staff, visitors, volunteers and students and not seek confidential information from any individual.
I will complete a pre-placement health screening which includes a 2-step tuberculosis test, laboratory tests and/or provide documentation of required immunizations.
Due to hospitalization at WRH, our clients are considered vulnerable. I will complete an extended criminal record check, which includes vulnerable sector screening and a check for pardoned sexual offences. (Do not complete until an interview with Volunteer Services Staff has taken place).
I will report to my shift "in uniform" and follow the dress code with my WRH photo ID clearly visible.
My services are donated to the hospital without contemplation of compensation or future employment.
I shall honour the duties and time commitment of the service assigned to, advising the Department of Volunteer Services of any planned absences and any emergency absences.
I will complete any/all orientation and training materials/sessions that are related to my volunteer service placement.
I understand that the Department of Volunteer Services reserves the right to terminate my volunteer status at any time due to:
a. Failure to comply with hospital policies, rules and regulations
b. Problematic attendance
c. Negative and/or inappropriate comments or conduct
d. Any other circumstances which, in the judgement of the Department of Volunteer Services makes my continued
service as a volunteer contrary to the best interests of the Hospital and its clients.
I understand that it is my responsibility to read and abide by the policies, procedures, and rules as stated in the Volunteer Orientation Materials, including but not limited to conduct and ethical guidelines, dress code and safety. I will consult the Department of Volunteer Services regarding any orientation topic that I do not understand. In the event the material is revised and/or otherwise updated, I will be informed and expected to abide by the most current instructions

* I have read each of the above conditions and I agree to abide by them.

* Applicant's Name:

* Date of Completion (mm/dd/yyyy):

Anything Else You Would Like Us to Know

*Optional* Please use this space to share any additional relevant experiences, skills, interests, availability details, accommodation needs, or other information you feel would be helpful for us to know.