BLOOD.CA WWW.BLOOD.CA WWW.BLOODShare your vitality

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 group’s name: ______________________

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Skills and Experience:

Volunteer/Work Experience: _____________________________________________________________________________________

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Special Skills and Experience: ___________________________________________________________________________________

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Profession: ____________________________________________________________________________________________________

Education: ____________________________________________________________________________________________________

Languages: Speak Write Both

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Preferred Language: ____________________________________________________________________________________________

Emergency Contact Name: ____________________________________________________________________________________

Phone Number: ______________________________ Relationship: ____________________________________________________

Are you a Current Blood Donor Past Donor N/A

Fluency

Volunteer Application Form

1000100852/2006-12-08

BLOOD.CA WWW.BLOOD.CA WWW.BLOODShare your vitality

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? _________________________________________________________________

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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: ___________________________________________________________________________

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Can you travel to neighbouring communities to volunteer?

Yes No

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

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What are the qualities you would bring to a volunteer assignment? ________________________________________________________

Describe your experiences dealing with the public: _______________________________________________________________________

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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.

Signature of Volunteer ___________________________________________

Date ___________________________________________

(Volunteers under the age of 16 are requested to provide parental consent)