Volunteer Application Form

Personal Information:
Last Name: _______________________________________ First Name: __________________________________________________
Preferred Salutation (eg. Ms. Miss. Mrs. Mr. Dr.) ______

Common Name: ____________________________________________

Telephone Numbers:

Home:_ _________________________________________________________________________________

Work: _____________________________________________________________ Ext.: _______________

Other: _____________________________________________________________ Ext.: _______________

Best Time to Call: _______________________________________________________________________________________________

Street Address: _________________________________________________________________________________________________
City/Town: _________________________________

Prov.: __________ Postal Code: _____________________________________

E-Mail Address: _________________________________________________________________________________________________

Nearest intersection to your home (if applicable): ___________________________________________________________________
Date of Birth: Year: _____________________ Month: ____________________ Day: ___________ Sex: M / F ___________________
(year optional if over 16)

Are you volunteering as part of a group?

Yes

No If yes, please indicate the groups name: _______________________

_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Skills and Experience:
Volunteer/Work Experience: ______________________________________________________________________________________
_______________________________________________________________________________________________________________
Special Skills and Experience: ____________________________________________________________________________________
_______________________________________________________________________________________________________________
Profession: _____________________________________________________________________________________________________
Education: _ ____________________________________________________________________________________________________
Fluency
Languages:

Speak

Write

Both

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Preferred Language: _____________________________________________________________________________________________
Emergency Contact Name: _____________________________________________________________________________________
Phone Number: _______________________________ Relationship: _____________________________________________________
Are you a

Current Blood Donor

Past Donor

N/A

1000100852/2006-12-08

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Availability:

Preferred Days

Number of Hours

Weekday Mornings: _________________________________________________________

______________________________

Weekday Afternoons: ________________________________________________________

______________________________

Weekday Evenings: _ ________________________________________________________

______________________________

Weekend Mornings: _________________________________________________________

______________________________

Weekend Afternoons: ________________________________________________________

______________________________

Weekend Evenings: _________________________________________________________

______________________________

Availablilty Comments: _ _________________________________________________________________________________________

How did you hear of this opportunity to volunteer? __________________________________________________________________
_______________________________________________________________________________________________________________
Volunteer Placement:
Please indicate the volunteer assignments or activities that interest you most:
1. _____________________________________________________________________________________________________________
2. _____________________________________________________________________________________________________________
3. _____________________________________________________________________________________________________________
4. _____________________________________________________________________________________________________________
Please complete the following as thoroughly as possible:
Do you have any physical or mental health conditions or other restrictions that could affect the kind of volunteer work you do?
Yes

No

Please describe: ____________________________________________________________________________

_______________________________________________________________________________________________________________
Can you travel to neighbouring communities to volunteer?
Yes

No

What are your reasons for wanting to become a volunteer? __________________________________________________________

_______________________________________________________________________________________________________________
What are the qualities you would bring to a volunteer assignment? _ ________________________________________________________
Describe your experiences dealing with the public: ________________________________________________________________________
_____________________________________________________________________________________________________________________
As part of our Business Continuity planning, Canadian Blood Services may need to call on volunteers to provide support where the availability
of our normal volunteer base has been impacted due to unforeseen events such as a national disaster, pandemic or neighbourhood emergency.
This would most likely be necessary in the event of such a scenario and only where circumstances might jeopardize our ability to ensure we
are able to respond to the urgent need for blood and blood products. In such a situation, on-call volunteers would be contacted to determine
their availability to assist where required.
Please check here if you are interested in being an on-call volunteer.

Any other information you think we should consider? _____________________________________________________________________

I authorize Canadian Blood Services to use my information for the purpose of processing my volunteer application, and to contact me by e-mail, phone or
mail about the volunteer program.
Privacy Statement: Canadian Blood Services respects your privacy and will not sell, rent or share your information with others. To read ourprivacy policy online
visit: http://www.blood.ca/privacypolicy.

Please read the following and sign below: I agree to abide by the policies and guidelines in place at Canadian Blood Services, if I am accepted
as a volunteer. I understand that volunteering is a responsibility and I will fulfill the requirements and time commitments of my assignment to
the best of my ability.
(Volunteers under the age of 16 are

Signature of Volunteer ____________________________________________ requested to provide parental consent)

Date ____________________________________________

Share your vitality