Geneva Centre for Autism

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Volunteering

Volunteer Appreciation

Student Placements

Donor / Support

Supporting Membership

Bhayana Award

* Required Fields

GENERAL INFORMATION
Mr. Mrs. Ms. Miss.
Today's date:*
Last Name:*
First Name:*
Address:*
Apt./Unit#:
City:*
Postal Code:*
Email address:*
Home Phone #:*
Business Phone #:
Cell Phone #:
Other Languages Spoken Fluently:

In an emergency, who can we call?

EMERGENCY NOTIFICATION
Name:*
Relationship:*
Home Phone #:
Business Phone #:
Cell Phone #:

HEALTH AND SAFETY
Clinical work with our clients can require: mobility, lifting 30kg, flexibility, quick action, high energy and good English. Do you possess these qualities?	Yes No If no, please explain:
Please Note: You will be required to complete a TB test and have a record of immunization if you are a clinical volunteer.

WORK AND EDUCATION HISTORY

Are you currently employed?*

Yes No
Full Time:
Part Time:
Retired:

If you are currently employed,

Where?

Phone #:

Job Title:

Work experiences:

Your level of education currently completed:*

High School	[ yrs]
College	[ yrs]
University	[ yrs]
Other

Diploma/Degree?

Specialization:

Are you currently a student?*

Yes No

Full time:
Part time:

REFERENCES (No relatives or friends)
Name:*
Position:*
Phone:*

Name:*
Position:*
Phone:*

VOLUNTEER EXPERIENCE
If you have volunteered before, please complete:
Name of Organization or Agency:
Type of Volunteer Activity:
Other Community Involvement:
Have you had previous experience working with children?	Yes No

WHAT ARE YOUR REASONS FOR VOLUNTEERING?
Put spare time to use:
Interest in community activity:
To establish work record:
Experience for career:
Desire to help others:
Contact with Autism:
Other, please describe:

SHARE WITH US SOMETHING ABOUT YOURSELF

AREAS OF INTEREST - What type of work would you enjoy the most?*
On-Site Respite:
In-Home Support:
Library:
Clerical:
Social Skills Group:
Fundraising:
On-site pre-school:
Off-site pre-school:
Board member:
Facilities upkeep:
Special projects:
Co-op:

TIME AVAILABILITY

Please mark the days and times you are available

	MON	TUES	WED	THURS	FRI	SAT	SUN
AM 9 - 12
PM 12-3
PM 3-6
EVE 6 - 9

By submitting this application I hereby affirm that:

all information is true and accurate;
I will respect the confidentiality of information regarding the children I work with;
I consent to a Police Reference Check and affirm that I have never been convicted of a crime for which a pardon has not been granted;
I give Geneva Centre for Autism permission to check references prior to placement.

Subject to our placement opportunities and your suitability, you will be contacted regarding an on-site interview. Depending on the area in which you volunteer, you may be required to submit to a Police Check. Placement with affiliated agencies is subject the volunteer policy of that agency.