volunteer application chilliwack health services - Fraser Health ...

VOLUNTEER APPLICATIONCHILLIWACK HEALTH SERVICESFor Office Use OnlyReceived Date: Interview Date: Orientation Date:ER WF AUX SL HV BC NC OtherThank you for your interest in volunteering with us. Please complete the required documents thoroughly. Incompleteapplications will not be considered.• Choose two references and provide them with a copy of the attached reference form and a blank sealable envelope.• Complete the attached Consent for Criminal Record Disclosure form and take it to the Chilliwack RCMP office at 45924Airport Road. They will process the form (at no cost) and sent the results directly to our office (approx. 10 business days).• Complete this application form and the Confidentiality Policy Acknowledgement and return them along with your 2 referenceforms (sealed) to: Chilliwack General Hospital Administration Office, 3 rd Floor B Wing, 45600 Menholm Road,Chilliwack, BC V2P 1P7.• If you have any questions, please contact CGH Administration at 604-795-4198 or email tracey.kirkness@fraserhealth.caDatePLEASE PRINTSurname Given Name InitialStreet Address City Province Postal CodeHome Phone Cell Phone EmailAge Group: 16-18 19-25 26-40 41-60 over 60IN CASE OF EMERGENCY NOTIFY:Name: ________________________ Relationship: ____________________ Contact #: ___________________Family Physician:___________________________________Phone: ______________________________Please describe any physical, mental or emotional conditions that may affect your service, or that you wish to betaken into consideration when determining placement:REASON(S) FOR VOLUNTEERINGPlease tell us why you would like to volunteer with Chilliwack Health Services? (2-3 sentences)WHERE WOULD YOU LIKE TO VOLUNTEER? (Rank 1 st , 2 nd , 3 rd preference). See page 3 for program details.Chilliwack Hospital AuxiliaryChilliwack Hospital Service LeagueWayfinding / Information DeskHeritage Village Residential CareEmergency DepartmentBradley Centre Residential CareNetCARE Day Program for Older AdultsOther (specify) _____________________EDUCATION HISTORYEducation (highest level completed)VOLUNTEER HISTORYList all previous/current volunteer experiences, including your role, the organization and approx. hours contributed.

EMPLOYMENT HISTORYBriefly describe your employment history. If available, please attach your resume.SKILLS AND INTERESTSList skills, interests, hobbies, and relevant personal experiences and training.Do you speak, read or write another language? No Yes _____________________ (specify)If yes, would you be willing and comfortable to translate for a patient/client/resident? No Yes What is your availability for volunteering? Check all boxes that apply.MorningAfternoonEveningMonday Tuesday Wednesday Thursday Friday Saturday SundayA minimum 60 hour commitment is required for most programs (1 2hr shift per week). Are you able to fulfill thiscommitment?Yes No If no, please explain: ______________________________________________A one year commitment (1, 3 ½ hr shift per week) is required for our Emergency department. Are you able to fulfillthis commitment?Yes No If no, please explain: ______________________________________________REFERENCES 2 are required, ie. employer, teacher, adult family friend (non-relatives only)Please list your references here and ask your reference to complete the attached reference form and return it toyou in a sealed envelope (to be forwarded with your application).1. Name Relationship Phone____________________________________________________________________________________2. Name Relationship Phone____________________________________________________________________________________Parent/Legal Guardian Consent: (applicants under 19 years of age)I, ________________________ (print your name) grant my child, ________________________ (child’s name), permission to participate in theVolunteer Program at Chilliwack Health Services.Signature of Parent/Guardian: ____________________________________________________ Date: __________________________** Please read the following carefully before signing this application **“I _______________________ (print your name) confirm that the information in this volunteer application is complete and true. I understandand agree that any omission or misrepresentation with respect to the information given may be cause for refusal of volunteer placement, or if Iam a volunteer of Fraser Health, may be cause for immediate termination. I authorize Fraser Health to contact the references listed and givepermission to these references to release all relevant information requested.I understand, and give permission for Fraser Health to keep a record of my personal information on site and that it will remain confidential toFraser Health. I understand that this information may be disclosed to any party with legal and proper interest, and I release the agency from anyliability whatsoever for supplying such information.Signature: ____________________________________________________________________ Date: _________________________Page 2 of 9

Chilliwack Health Services Volunteer OpportunitiesCHILLIWACK HOSPITAL AUXILIARY wasformed in 1911 to provide special services andprograms that contribute to the quality of care forour patients, families and visitors. Many of theirprograms generate funding for the purchase ofspecialized hospital equipment.Auxiliary Volunteers assist in the following areas:the Information Desk, Shopping Cart, KnittingCase, Ambulatory Day Care Program and OutpatientDiabetes Clinic. They also operate TheThrift Shoppe (Main St.) and the Heritage VillageGift Shop.Chilliwack Hospital Auxiliary business meetingsare held every 2 nd Monday at the ChilliwackUnited Church lounge.Contact: Jean Northgraves, MembershipPhone: 604-794-7366SERVICE LEAGUESince 1935, members of the Service Leaguehave been generously supporting ChilliwackHealth Services with special services andfundraising.Service League Volunteers assist in the followingareas: the CGH Gift Shop, Surgical Day Care,Eye Clinic, Orthopedic Clinic, Ambulatory DayCare and the NU5 General Rehab daily teaservice. They also assist with various specialevents.Service League business meetings are heldmonthly.Contact: CGH AdministrationPhone: 604-795-4198WAYFINDINGCGH provides a wide variety of patient services,clinics and acute programs. Volunteers serve a keyrole in directing and leading patients and visitors totheir desired destination.Contact: Elizabeth Knowles, Volunteer Team LeaderPhone: 604-792-0188EMERGENCY DEPARTMENTThe volunteer’s role in the ER is to provideinformation, support, and comfort to patients, familiesand visitors in the registration/waiting area. Avolunteer is often the first contact for Emergencypatients, setting the stage for a positive experiencefor each patient and their accompanying familymember or friend.This opportunity is offered to high school graduatesconsidering a career in health; or retired professionals.A one year commitment to this position isrequired.Contact: Marg Bartel, Volunteer CoordinatorPhone: 604-702-2858* YOUTH VOLUNTEER OPPORTUNITIESGrade 11 and 12 students are invited to volunteer atHeritage Village or Bradley Centre Residential Care.A 6 month minimum commitment is required for mostprograms. See program descriptions for details.Volunteer application forms are available fromany of the programs listed above or from theCGH Administration office, 3 rd floor B Wing.RESIDENTIAL CARE *Bradley Centre and Heritage Village are bothResidential Care Facilities. Volunteers play avital role in the provision of recreational andtherapeutic programs for Residents, including:Crafts Games, Bingo1:1 Visiting Coffee TimeMusic Therapy Spiritual ActivitiesBus Outings Reading ProgramsSpecial Events Computer AssistanceA 6 month minimum volunteer commitment isrequired.Bradley Centre *Located at CGH, 45600 Menholm Rd.Hodgins St. Entrance, 2 nd FloorContact: Brenda Kinch, Recreation TherapistPhone: 604-702-4767Heritage Village *7525 Topaz Drive in SardisContact: Kevin Davey, Residential Leisure ServicesCoordinator and Volunteer CoordinatorPhone: 604-793-7141NETCARE DAY PROGRAM FOR OLDER ADULTSNetCARE at Parkholm Place is a day programthat supports older adults and their caregivers.The program operates 8-4 pm, Monday toFriday. Volunteers assist with a variety ofactivities including:Games, BingoWoodworkingOutside WalksLunch AttendantHydrotherapy PoolFriendly VisitingSpecial EventsGardening GroupHymn Sing / MusicA 30 hour min. volunteer commitment is required.Located at Parkholm Place9090 Newman RoadContact: Jan McDermott, Team LeaderPhone: 604-795-4126

CONFIDENTIALITY POLICYACKNOWLEDGEMENTPurpose and PrinciplesEmployees and volunteers are required to ensure the confidentiality of patient/resident/client informationand exercise discretion when discussing the business of Fraser Health. This policy addresses theresponsibility of employees and volunteers to protect patient/resident/client privacy and confidentialbusiness information. The Collection, use and disclosure of personal information is governed by theFreedom of Information and Protection of Privacy Act.ApplicationAny person working or volunteering in or for Fraser Health is required to adhere to the principlesdescribed herein.PolicyUnder no circumstances may any patient/resident/client information, in any form, (including electronicinformation systems) gained within FH be divulged inside or outside of FH, other than to those personsauthorized to receive such information in the course of their duties.Under no circumstances will an employee or volunteer access data relating to patients/residents forwhich they have no responsibilities or unrelated responsibilities.Under no circumstances will information, in any form, (including electronic information systems)concerning FH organizational, financial, business or human resource matters be divulged inside oroutside of FH, other than as authorized by FH. Under no circumstances will an employee or volunteerpermit unauthorized access or usage of FH information.Confidentiality is to be preserved while at work and after work has ended.A staff member or volunteer determined to be in violation of this policy will be subject to discipline, up toand including termination.I have read and understand the content of this policy:__________________________________Name (please print)__________________________________Signature_____________________________DateParent/Guardian Acknowledgement (for applicants under 19 years of age)__________________________________Signature of Parent/Guardian_____________________________Date

Chilliwack General Hospital45600 Menholm RoadChilliwack BC V2P 1P7604-795-4141Applicant: please complete the first two blanks and give this form, along with a blank sealable envelope, to yourreference to complete and return to you (sealed in the envelope).Dear Sir/Madame,________________________________ , is applying to volunteer at Chilliwack Health Services_________________________________ (program name).He/she has listed you as one of two required references and has given permission to Fraser Health(FH) to contact you if needed re providing a reference in support of their application.Your assistance in providing us with the following assessment and feedback is appreciated.Scale: NA (not applicable)P (poor), F (fair), G (good),VG (very good)Dependability:Responsibility/Accountability:Initiative:NA P F G VG NA P F G VGProblem Solving:Organizational/Prioritizing:Leadership:Team Player: Teaching/Mentoring:Flexibility/Adaptability:Honesty/Integrity:Verbal & Written:Work Attendance:1. Please describe the applicant’s strengths:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. Opportunities for improvement:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Page 5 of 9

3. Interaction with others:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Would you recommend this applicant for this position: Highly Recommended Recommended with Reservations Recommended Not RecommendedPlease feel free to provide any additional information to support your reference:______________________________ ___________________________ ________________Name (please print) Signature DateRelationship to Applicant ________________________________Contact number: _______________________________________Please return this form to the applicant, sealed in the envelope they have provided.Thank you for your time and consideration in providing this reference.Page 6 of 9

Chilliwack General Hospital45600 Menholm RoadChilliwack BC V2P 1P7604-795-4141Applicant: please complete the first two blanks and give this form, along with a blank sealable envelope, to yourreference to complete and return to you (sealed in the envelope).Dear Sir/Madame,________________________________ , is applying to volunteer at Chilliwack Health Services_________________________________ (program name).He/she has listed you as one of two required references and has given permission to Fraser Health(FH) to contact you if needed re providing a reference in support of their application.Your assistance in providing us with the following assessment and feedback is appreciated.Scale: NA (not applicable)P (poor), F (fair), G (good),VG (very good)Dependability:Responsibility/Accountability:Initiative:NA P F G VG NA P F G VGProblem Solving:Organizational/Prioritizing:Leadership:Team Player: Teaching/Mentoring:Flexibility/Adaptability:Honesty/Integrity:Verbal & Written:Work Attendance:2. Please describe the applicant’s strengths:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. Opportunities for improvement:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Page 7 of 9

3. Interaction with others:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Would you recommend this applicant for this position: Highly Recommended Recommended with Reservations Recommended Not RecommendedPlease feel free to provide any additional information to support your reference:______________________________ ___________________________ ________________Name (please print) Signature DateRelationship to Applicant ________________________________Contact number: _______________________________________Please return this form to the applicant, sealed in the envelope they have provided.Thank you for your time and consideration in providing this reference.Page 8 of 9

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