VOLUNTEER SERVICES APPLICATION PACKAGE
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1 VOLUNTEER SERVICES APPLICATION PACKAGE Applicatin Checklist Applicatin Frm Letter fr Criminal Recrd Check Vlunteer Reference Frm Infrmatin abut Immunizatins Infrmatin fr High Schl students
2 VOLUNTEER SERVICES APPLICATION CHECKLIST Vlunteering with Yukn s hspitals is a cmmitment and it s imprtant t recgnize the rle and requirements fr vlunteers. As part f the applicatin prcess, there are several steps yu will need t cmplete. This checklist is designed t help yu cmplete all f the sectins f applicatin alng with several additinal tasks. Please take the time t ensure that all dcumentatin is cmplete and that yu have attached all relevant supprting dcumentatin befre submitting yur applicatin. Cmplete all sectins f the Vlunteer Applicatin Package Obtain a Criminal Recrd Check frm the lcal plice detachment Update all immunizatins as required & prvide immunizatin recrd Review and sign the Vlunteer Declaratin Review and sign the Student Agreement (if applicable) Include tw cmplete Reference Frms Vlunteer Enrlment Prcess & Imprtant Infrmatin Submit a cmpleted applicatin frm. If a suitable rle is available, the Crdinatr f Vlunteer Services will cntact yu t schedule and cnduct an interview. If yur skills match the vacancy, yu will be requested t attend an rientatin sessin that will take up t tw hurs. Upn cmpletin f the rientatin yu will be ffered a suitable vlunteer placement. Receive yur vlunteer handbk, unifrm & ID Badge. (A $20.00 refundable depsit is required fr yur unifrm & ID badge. Additinal unifrms, if requested by the vlunteer are $20.00 each. The nn-refundable replacement fee fr a lst ID badge is $20.00) Training will be prvided within the assigned department. Once trained, a regularly scheduled shift will be assigned. Evaluatin, supprt and supervisin will be prvided n an n-ging basis
3 VOLUNTEER SERVICES APPLICATION FORM **Applicants must be a minimum age f 15 years t apply** SECTION 1 CONTACT INFORMATION Last Name D.O.B. (MM/DD/YYYY-Optinal) Street Address City Prv/Terr In case f emergency, we shuld cntact: Name Hme Phne Relatinship t yu First Name Hme Phne Cell Pstal Cde Cell Wrk Phne Can we cntact yu fr the purpses f vlunteering in ur hspitals? Yes N Hw d yu prefer t be cntacted (please check ne) Hme/Phne/Cell/ /Other Hw did yu learn abut ur vlunteer prgram? (please circle all that apply) Newspaper Friend Pster/Ad Website Other SECTION 2 EDUCATIONAL BACKGROUND Highest Level f Educatin Cmpleted Cmpleted In Prgress Area(s) f Study FOR HIGH SCHOOL STUDENTS ONLY Name f Schl Current Grade SECTION 3 - LANGUAGES Please indicate which language(s) yu speak and/r write fluently English (Verbal) Written French (Verbal) Written Other Wuld yu feel cmfrtable speaking with patients/visitrs in French? YES/NO
4 SECTION 4 SELF-IDENTIFICATION D yu cnsider yurself t be f First Natins, Inuit r Metis ancestry? YES?NO If yes, please describe: D yu have specific backgrund, experience r interest in wrking with Indigenus patients r initiatives? SECTION 5 GENERAL HEALTH STATUS D yu have any cnditins/restrictins that wuld impact yur ability t perfrm yur vlunteer duties safely? YES/NO If yes, please describe: SECTION 6 INTERESTS & EXPERIENCE Why wuld yu like t vlunteer in Yukn s hspitals in particular? Which vlunteer prgrams interest yu the mst and match yur schedule? List in rder f preference: List any skills, experience, hbbies r interests:
5 SECTION 7 - AVAILABILITY Please indicate yur availability nting specific times that yu are able t vlunteer (Mst vlunteer shifts are 2-3 hurs in length) Mnday Tuesday Wednesday Thursday Friday Saturday Sunday Mrning Afternn Evening Schedule is valid frm: t We ask that all vlunteers prvide 60 hurs f service within a 6 mnth perid. Student Applicants: Please review the attached Imprtant Infrmatin fr Students frm befre filling ut yur availability.
6 CRIMINAL RECORD CHECK REQUEST LETTER YUKON HOSPITAL CORPORATION VOLUNTEER SERVICES Dear RCMP Detachment Staff: Nte: Yu will need t g in persn t yur lcal RCMP r plice statin and fill in the Criminal Recrd Check frm (including the vulnerable sectr sectin) in rder t allw yu t vlunteer with Yukn Hspitals. Please be sure t bring tw pieces f I.D. Please submit this frm as sn as pssible; it must be returned t WGH Vlunteer Services befre yu can vlunteer. There is n cst fr this service. has applied t vlunteer with the Yukn Hspital Crpratin (Name f vlunteer) at Whitehrse General Hspital. YHC (Vlunteer Services) is requesting that the bearer f this letter be screened thrugh the Vulnerable Sectr Security Clearance prcess fr the purpse f vlunteering in the hspital. Shuld yu have any questins, please cntact me directly. Sincerely, Crystal Shimn Crdinatr, Vlunteer Services & Patient Supprt Yukn Hspital Crpratin 5 Hspital Rad Whitehrse, YT, Y1A 3H7 Direct Phne: (867) Crystal.Shimn@wgh.yk.ca
7 IMPORTANT INFORMATION REGARDING IMMUNIZATIONS YUKON HOSPITAL CORPORATION VOLUNTEER SERVICES Thank yu fr applying t vlunteer with the Yukn Hspital Crpratin at Whitehrse General Hspital! YHC (Vlunteer Services) requires that yu underg screening fr Tuberculsis and update yur required immunizatins. As per hspital plicy (Cmmunicable Disease OHS 060), we require specifically that yur MMR (Measles, Mumps & Rubella) & TDAP (Tetanus, Diphtheria, Pertussis) and Varicella immunizatins are updated r deemed immune per the vaccine prgram. Depending n yur cuntry f rigin, yu may require ther immunizatin updates This can be cmpleted at WGH with Samantha Stewart ( ), r at the Whitehrse Health Centre (please phne t make an appintment ). The Health Nurse will review yur immunizatin histry and g ver yur needs with yu, including dcumentatin t verify that yu have been recently screened fr TB. Prir t yur first day as a vlunteer, please visit yur lcal Health Center t verify that all f yur immunizatins are up t date. **Please ask yur health care prvider t cmplete the chart belw and return t me prir t yur first day as a vlunteer. If yu are frm ut f the Territry, r are unable t access yur immunizatin histry, yu will need t speak t yur health care prvider abut btaining these recrds. This can be dne with assistance frm Samantha Stewart (WGH) r at the Whitehrse Health Center. IMMUNIZATION HISTORY TO BE COMPLETED BY HEALTH NURSE IMMUNIZATION UP TO DATE OR NURSE INITIALS OTHER COMMENTS IMMUNE MMR TdAP VARICELLA TB SCREENING NO EVIDENCE OF ACTIVE TB CLIENT ALSO PROVIDED WITH LETTER DATE FORM COMPLETED: RN s SIGNATURE: Shuld yu have any questins, r require any further infrmatin, please cntact: Crystal Shimn Crdinatr, Vlunteer Services & Patient Supprt Yukn Hspital Crpratin 5 Hspital Rad Whitehrse, YT, Y1A 3H7 Direct Phne: (867)
8 IMPORTANT INFORMATION FOR STUDENTS STUDENT AGREEMENT YUKON HOSPITAL CORPORATION VOLUNTEER SERVICES THANK YOU FOR YOUR INTEREST IN VOLUNTEERING WITH YUKON HOSPITALS! We greatly value the imprtant rle and cntributin f yuth in ur vlunteer cmmunity and we welcme and encurage yu t apply t any f ur student vlunteer psitins. When preparing an applicatin, please cnsider yur ability t fully cmmit t the prgram and the patients at the hspital. Student vlunteers must be able t maintain their cmmitment t their vlunteer placement even during perids f heavy schl wrklad and exams. Students with a heavy curse lad r a large number f extra-curricular activities may wish t wait t apply fr the prgram. Please nte that the vlunteer prgram runs cntinuusly, regardless f high schl exams and schl/territrial hlidays. COMMITMENT: Over the curse f the high schl year, we require a 60 hur vlunteer cmmitment in rder t prvide yu with yur certificate f cmpletin. If yu wish t accelerate the cmpletin f yur vlunteer hurs, please speak t the Vlunteer Crdinatr. Fllwing the submissin f a cmplete applicatin, yu will be cntacted fr an interview. Frm that pint, yu must attend a 2 hur rientatin sessin. An apprpriate psitin will be assigned t yu based n persnal skills, preference and fit. Yu will als receive further training specific t yur rle. (All time spent rientatin and training will be nted). Yu will be assigned a regular shift that will be scheduled n a mnthly rtatinal basis. All effrts will be made t find the shift that fits best with yur schedule. Yu are expected t ntify the vlunteer crdinatr in the instance f late arrival/absences. As with all hspital vlunteers, yu must abide by the plicies and prcedures as utlined in the Vlunteer Handbk. It is expected f all vlunteers that yu are reliable, punctual and arrive with yur unifrm and ID Badge fr each shift. As a vlunteer, yu are expected t abide by the Standards f Cnduct Plicy (CO-110) and sign and respect the Cnfidentiality Agreement (LI-060). PLEASE SIGN AND DATE THIS STUDENT AGREEMENT I, acknwledge the Student Agreement and cmmit t abiding by these expectatins and respnsibilities while acting as a vlunteer at Yukn Hspitals. Date:
9 VOLUNTEER REFERENCE FORM YUKON HOSPITAL CORPORATION VOLUNTEER SERVICES Thank yu fr taking the time t cmplete this Reference Frm. Please nte that references must have knwn the applicant fr a minimum f six mnths and cannt be family members r friends. References may be cntacted fr additinal infrmatin. Name f Vlunteer Applicant: REFERENCE INFORMATION Last Name Telephne First Name What is yur relatinship t the applicant? (e.g. emplyer, teacher) Hw lng have yu knwn the applicant? PLEASE RATE THE APPLICANT IN THE FOLLOWING AREAS Reliability and Cmmitment Respnsibility/Accuntability Interpersnal Skills Cmmunicatin Skills Teamwrk and Cperatin Cmpassin fr thers Respectfulness f thers Adaptability Wuld yu recmmend this applicant t vlunteer with Yukn Hspitals, knwing that they will be wrking with vulnerable peple? POOR FAIR GOOD EXCELLENT NOT SURE YES NO MAYBE Other Cmments: Reference Signature: Date: PLEASE COMPLETE THIS FORM AND RETURN TO THE APPLICANT. REFERENCES MUST BE SUBMITTED TOGETHER WITH THE APPLICATION FORM.
10 VOLUNTEER DECLARATION PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING & DATING THIS APPLICATION Yukn Hspital Crpratin (YHC) reserves the right t accept r nt accept vlunteer applicants. Vlunteers are placed accrding t their interests, skills, suitability, and the needs f the hspital. YHC reserves the right t release a vlunteer frm his/her vlunteer psitin if, in the pinin f YHC, cntinuance f the vlunteer rle culd cause detriment t the hspital. By signing, I cnfirm that the infrmatin in this vlunteer applicatin is cmplete and true. I understand and agree that any missin r misrepresentatin may be cause fr refusal f vlunteer placement, r if I am a vlunteer fr Yukn Hspital Crpratin, may be cause fr immediate terminatin. I authrize Yukn Hspital Crpratin t cntact the references listed and give permissin t these references t release all relevant infrmatin requested. I als understand that by signing this vlunteer applicatin frm, YHC will keep a recrd f my persnal infrmatin n site and that it will remain cnfidential t YHC. I understand that persnal infrmatin n this frm is cllected, used and disclsed by YHC in accrdance with the Access t Infrmatin and Prtectin f Privacy Act (ATIPP), and that if I have any questins abut the cllectin and use f my infrmatin, I can cntact YHC s Infrmatin Privacy Office at r YHCPrivacy@wgh.yk.ca. Applicant Signature: Date: Parent/Legal Guardian Cnsent: (applicants under 19 years ld) I,, give my child/ ward, permissin t vlunteer in Yukn s hspitals. Signature f Parent/Guardian: Date:
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