Volunteer Screening Form printable pdf download

Volunteer Resources

Volunteer Screening Form

Gender:  female male

Today’s date: _______________________

First name: _______________________ Last name: _______________________

Birth date: (mm/dd/yyyy) _____________

Address: ________________________________ City: __________________ Postal code: __________

Email: __________________________________ Home phone: ___________ Cell phone: __________

Attach resume if desired

Volunteer History:

Employer: ________________________

Phone: __________ Date/From: _____________ To:__________

Duties: ______________________________________________________________________________

Employment History:

Employer: _________________________ Phone: __________ Date/From: _____________ To:__________

Duties: ______________________________________________________________________________

Languages Spoken: ___________________________________________________________________

Training: (e.g.: first aid, Food Safe etc…) Course: __________________________________________

Are there any health problems or restrictions that may affect your volunteer work? No ____ Yes ____

Emergency Contact Name: ________________

Relationship: ________________________

Home phone: ___________________________

Cell phone: _________________________

Check the days of the week you are available:

Mon: Am___Tue: Am___ Wed: Am___ Thurs:Am ___Fri: Am ___ Sat: Am ___ Sun: Am ___

Pm___

Pm ___

Pm___

Pm ___

Please indicate age groups you are interested in volunteering with:

___Preschool (3-5 yrs) ____Children (6-12 yrs)

____Pre-teen (11-18 yrs

___Adults

___Seniors

Indicate type of volunteer work: _______________________________________________________________

Other information: __________________________________________________________________________

Volunteer placements are made on the basis of skills, experiences and program requirements.

Are you interested in working with people with disabilities?

___Yes

___No

Are you a student?

___Yes

___No

Are you a Career Preparation student?

___Yes

___No

Consent

This information is collected under the Freedom of Information and Protection of Privacy Act and is necessary for the operation of a City

program or activity. The information provided will be used internally for the purpose of IDENTIFYING and CONTACTING you as a City of

Burnaby volunteer.

I am aware of the nature of the activities and duties for which I have volunteered and hereby confirm that I am physically and otherwise able

to perform the volunteer duties without injury or harm to myself or to others.

I understand that some volunteer activities involve travel and I agree to inform myself of the nature and scope of travel before accepting any

volunteer assignment.

Volunteer Signature

Date

_______________________________

_________________

Parent Signature: _________________

_________________

(Volunteer is under 19 years)

Criminal record checks will be undertaken for potential volunteers 19 years and up when filling positions, that handle financial transaction; or that are

considered to or potentially having interaction or contact with children and vulnerable persons.

Volunteer Screening Form

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