VOLUNTEER APPLICATION FORM

Date:  					

NAME:      												

ADDRESS:												

 CITY:  						   POSTAL CODE: 				

TELEPHONE:						

AGE:			  16-19	  20-29	  30-49	  50+

LANGUAGES:		    English	    French	  Other:  				

SKILLS & INTERESTS:																																																												___________

VOLUNTEER EXPERIENCE:																																																																																							

Revised June 2004

- 2 -

Is there a particular type of volunteer experience that interests you?  Check all that apply.

	Working directly with a client  *
	Working directly with a staff person as an assistant  *
	Working independently in my own home or in the workplace
	Helping with general office administrative duties
	Working as a Board or Committee Member
	Participating in public speaking, fundraising, special events
	No preference
	Other:												

( * Does not involve unionized staff responsibilities)

When are you available to volunteer?

	Flexible		Days			Evenings		Weekends
	There are times when I cannot volunteer:  							

What date was your Police Check done?	        							

Why have you chosen Community Living Espanola for your volunteer service?

REFERENCES:

Name:								Telephone: 				
Address:						
Name:								Telephone: 				
Address:						
Name:								Telephone: 				
Address:						

	      Signature				       Parent/Guardian if under 18 years

Please send this application to:	Community Living Espanola 
					345 Centre Street
					Espanola, Ontario
					P5E 1E4