Required fields are marked with asterisks (*)

Long Term Care Homes Volunteer Application

Please indicate the Home you would like to consider this application for:

Bonnechere Manor (Renfrew)

Miramichi Lodge (Pembroke)

Applicant Information

Last Name

First Name

Street Address

City, Province

Postal Code

Home Phone:

Cell Phone:

Email Address

Name and address of school (if presently attending)

Emergency Contact:

Last Name:

First Name:

Relation:

Home Phone:

Business Phone:

Requirements

All employees, volunteers are expected to review and sign a confidentiality policy related to the safeguarding of information related to residents, employees, volunteers and Home business.

Submission of a Vulnerable Sector Criminal Record Check and Pardoned Sexual Offender’s Database Check from the police detachment responsible for the jurisdiction of your place of residence. Going forward, you are required to disclose immediately to the Employer if you are charged with an offence or issued an order under sections 9 (a) – (d) below. Failure to do so will result in a termination of volunteer status:
- (a) Every offence with which the person has been charged under the Criminal Code (Canada), the Controlled Drugs and Substances Act (Canada) or the Food and Drugs Act (Canada) and the outcome of the charge.
- (b) Every order of a judge or justice of the peace made against the person in respect of an offence under the Criminal Code (Canada), the Controlled Drugs and Substances Act (Canada) or the Food and Drugs Act (Canada), including a peace bond, probation order, prohibition or warrant.
- (c) Every restraining order made against the person under the Family Law Act or the Children’s Law Reform Act.
- (d) Every offence of which the person has been convicted under the Criminal Code (Canada), the Controlled Drugs and Substances Act (Canada) or the Food and Drugs Act (Canada).
Submission of proof of current influenza vaccine (or satisfactory medical documentation that demonstrates the vaccine is medically contraindicated). If the vaccine is not available, it is the Employer’s expectation that you will get the flu vaccine on an annual basis.

Provincially directed COVID-19 testing

Criminal Reference Check (within last year): Please note that a letter from the Home can be provided for the request.

I have

I will obtain

Proof of Vaccination or Immunity to the following:

Tuberculosis Test – Step One (within last year)

I have

I will obtain

Tuberculosis Test – Step Two

I have

I will obtain

Assests

The following are considered assets. Please indicate if you currently have these assets:

Previous or present volunteer placements:

Special interests/hobbies:

Training or Courses:

Additional information:

The Auxillary Group is a vountary group of persons who are interested in the well-being of the Residents within the Home. This group meets monthly to review accomplished and futuer volunteer tasks undertaken by the Auxillary on both a regular and occasional basis on behalf of the Home.

Would you be interested in joining the Auxillary?

Yes

Availability:

Short Term

Long Term

References: (one professional, one personal)

Name: (professional)

Address: (professional)

Phone: (professional)

Name: (personal)

Address: (personal)

Phone: (personal)

Please sign

Clear

Today's Date

Long Term Care Homes Volunteer Application

Applicant Information

Emergency Contact:

Requirements

Assests

References: (one professional, one personal)

Apply

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