OFFICE USE ONLY
VOLUNTEER SERVICES
Date received:
APPLICATION FORM
*Demandez nous pour un formulaire de demande en français.*
Put into VSys:
**Applicants must be a minimum age of 15 years to apply.**
Please take the time to answer each question carefully and make sure to fill out the form completely.
Remember to include TWO completed Reference forms with this application. Only successful applicants will
be contacted for an interview in the next step to becoming a volunteer with Health Sciences North.
PERSONAL INFORMATION
Family Name:
Given Name:
Address:
City:
Postal Code:
E-mail:
Home Phone:
Cell:
How do you prefer to be contacted: (Please check one):
ADULT:
Current status that
best describes you:
(Please check ONE)
Home Phone Cell E-mail  Other:
✔
 Employed
STUDENT:
 High SchoolCurrent grade:____
 University/College studentCurrent year:_____
✔
 Seeking employment
✔
 Retired
✔
 Other:_____________________
EDUCATION
School:
Grade/Year completed:
Degree/Program:
(Post-Secondary)
LANGUAGES
Languages spoken:
 English  Français
Other:_____________________________________________
AVAILABILITY
Please mark (with an “X”) the day(s) and time slot(s) when you will be available for your assignment:
Hours
Morning
SUN
MON
TUE
WED
THU
FRI
SAT
(Any time between 7am to 12pm)
Afternoon
(Any time between 12pm to 4pm)
Evening
(Any time between 4pm to 7pm/10pm)
FOR STUDENTS ONLY: I am only applying for (Please check ONE):
 Academic Year schedule University/College (September-May) and High School (September-June).
 Summer ProgramUniversity/College students (May-August) and High School students (July-August).
 Both Summer Program and Academic Year schedule.
MANDATE
Have you been convicted of a criminal offence for which a pardon has not been granted?
 No  Yes
Page 1 of 2
Revised Nov. 2014
Why would you like to volunteer at Health Sciences North in particular?
Please indicate the volunteer position(s) / area(s) that are of interest to you. Please check ALL those that
apply.
 Direct patient contact
 Way-finding / Information Desk
 Other:_______________________
 Limited patient contact
 Cancer Centre
 Mental Health
 Physiotherapy/ Exercise
 Clinical support, assisting staff and patients (e.g. Emergency, Breast Screening, Cancer Clinics, Day Surgery, etc…)
 I have been in contact with a supervisor regarding a specific position (please specify supervisor’s name, as well
as the position discussed):___________________________________________________________________
What skills, interests, hobbies, training or experience do you have that you feel will contribute to your
success as a volunteer with HSN? Please check ALL those that apply.
 Music
 Administrative work
 Arts and crafts
 Data entry
 Work with children
 Knitting
 Research
 Revenue / Retail services
 Customer Service
 Fundraising
 Computer / IT
 Sports / Exercise / Physical activities
 Other:_____________________________________________________________________________________
Do you agree to commit to at least 6 consecutive months of service, volunteering two to six hours per
week? (This is with the exception of the Summer Program.)
 No  Yes
ACKNOWLEDGEMENTS
During the interview, we match your skills, interests and needs to opportunities available.
I acknowledge that there are some positions that may require a police records check and/or a driver’s licence.
I certify that the statements made on this application are true.
I understand that as a volunteer I may be exposed to various circumstances. These can include, but are not limited to
the following experiences: disturbing incidents and perhaps crisis situations. Your health and safety is HSN’S utmost
priority. For further information please feel free to discuss this with a Volunteer Advisor.
_________________________________________________
Applicant
_____________________
Date
_________________________________________________
Parent or Guardian for Applicant Under 18 Years of Age
_____________________
Date
Thank you for applying!
Confidential when completed.
Completed applications can be faxed, Emailed, mailed or handed in person to the Volunteer Services office:
Health Sciences North- Volunteer Services  41 Ramsey Lake Road  Sudbury, ON  P3E 5J1
Phone: (705) 523-7179, ext. 3  Fax: (705) 523-7037  Email: [email protected]
Page 2 of 2
Revised Nov. 2014
VOLUNTEER SERVICES
Services des bénévoles
REFERENCE FORM / formulaire de référence
A teacher, coach, clergy, neighbour, employer, camp counsellor, volunteer supervisor, or someone that
knows you well should provide the reference. Family members or friends are not recommended references.
This individual is applying to do volunteer work at Health Sciences North/Horizon Santé-Nord. As a
volunteer this individual may have contact with people who are vulnerable, recovering from illness or have
special needs. Volunteer activities may include visiting, offering support and comfort, handling cash, and
working in positions of trust and confidentiality. Volunteers are required to work cooperatively with
employees, visitors and other volunteers.
Name of Volunteer: ____________________________________________________________________
Name of Reference: _____________________________________Phone:________________________
Organization:_____________________________________Title:________________________________
How well do you know the applicant?
 very well

How long have you known the applicant?  < 6 months
well
 casually
 1 – 5 years  5+ years
In what capacity do you know the applicant? _____________________________________________
Please check the following:
Reliability
Responsibility
Trustworthiness
Self-direction
Cooperation
Interpersonal skills
Compassion for others
Respectfulness of others
Adaptability
Poor









Fair









Good









Excellent Unable to Judge


















Do you think the applicant works better:
 independently  one-to-one  as a team member  in any combination of situations  unable to judge
Comments:________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Do you consider the applicant suitable to be a volunteer at HSN knowing that he/she may not
receive direct supervision?  YES
 NO
 MAYBE
All information provided is CONFIDENTIAL. Please return completed form:
 to the applicant in a sealed, signed envelope or
 fax it to 705-523-7037 or
 email it to [email protected]
If you prefer to contact HSN Volunteer Services directly please call 705-523-7179
Health Sciences North/ Horizon Santé-Nord
Volunteer Services
41, chemin lac Ramsey Lake Road
Sudbury, ON P3E 5J1
Thank you for your time.
Signature: ________________________________________________________Date:______________________
NEW reference form.docx
Page 1
VOLUNTEER SERVICES
Services des bénévoles
REFERENCE FORM / formulaire de référence
A teacher, coach, clergy, neighbour, employer, camp counsellor, volunteer supervisor, or someone that
knows you well should provide the reference. Family members or friends are not recommended references.
This individual is applying to do volunteer work at Health Sciences North/Horizon Santé-Nord. As a
volunteer this individual may have contact with people who are vulnerable, recovering from illness or have
special needs. Volunteer activities may include visiting, offering support and comfort, handling cash, and
working in positions of trust and confidentiality. Volunteers are required to work cooperatively with
employees, visitors and other volunteers.
Name of Volunteer: ____________________________________________________________________
Name of Reference: _____________________________________Phone:________________________
Organization:_____________________________________Title:________________________________
How well do you know the applicant?
 very well

How long have you known the applicant?  < 6 months
well
 casually
 1 – 5 years  5+ years
In what capacity do you know the applicant? _____________________________________________
Please check the following:
Reliability
Responsibility
Trustworthiness
Self-direction
Cooperation
Interpersonal skills
Compassion for others
Respectfulness of others
Adaptability
Poor









Fair









Good









Excellent Unable to Judge


















Do you think the applicant works better:
 independently  one-to-one  as a team member  in any combination of situations  unable to judge
Comments:________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Do you consider the applicant suitable to be a volunteer at HSN knowing that he/she may not
receive direct supervision?  YES
 NO
 MAYBE
All information provided is CONFIDENTIAL. Please return completed form:
 to the applicant in a sealed, signed envelope or
 fax it to 705-523-7037 or
 email it to [email protected]
If you prefer to contact HSN Volunteer Services directly please call 705-523-7179
Health Sciences North/ Horizon Santé-Nord
Volunteer Services
41, chemin lac Ramsey Lake Road
Sudbury, ON P3E 5J1
Thank you for your time.
Signature: ________________________________________________________Date:______________________
NEW reference form.docx
Page 1
Health Surveillance
Applicant: __________________________________
Volunteer
Co-op student
Purpose:

The purpose of this Health Surveillance is to screen you for communicable diseases and determine if
you can begin your role as a volunteer with HSN.
Instructions:


As a condition of acceptance into the Volunteer Services program and in accordance with HSN’s
Health Care Worker Communicable Disease Surveillance program policy, you are required to meet
the immunization requirements outlined on the form in full and return to the Volunteer Services
department.
These tests can be done at your doctor’s office, a walk-in clinic, at the Sudbury and District Health
Unit or possibly at your educational institution. Please note: charges may apply.
Immunization status:
**All documented vaccinations/TB testing on this form must be supported with a copy of the immunization
records or proof of immunization from the person who administered the vaccine/TB TESTS.
Measles
Mumps
Rubella
Option 1. Laboratory evidence of
immunity (titres)
Or
Date of lab test:
Option 2. MMR vaccines
Date of 1 MMR:
Date of 2 MMR:
Date of lab test:
___ Immune
___ Not immune
Option 1. Laboratory evidence of
immunity (titres)
Or
Option 2. MMR vaccines
Option 1. Laboratory evidence of
immunity (titres)
Or
Option 2. MMR vaccines
Varicella
Tetanus/
Diphtheria/
Pertussis
___ Immune
___ Not immune
st
nd
st
nd
Date of 1 MMR:
Date of 2 MMR:
Date of lab test:
___ Immune
___ Not immune
st
nd
Date of 1 MMR:
Date of 2 MMR:
Option 1. Laboratory evidence of
immunity (titres)
Date of lab test:
Or
Option 2. Varicella vaccine (2 doses
st
Date of 1 dose:
required)
All adult health care workers (18 years or older) are required to
receive a single dose of tetanus diphtheria acellular pertussis (Tdap)
for pertussis protection if not previously received in adulthood.
Tetanus/Diphtheria should be given at 10 year intervals thereafter.
4 1 , c h e m i n d u l a c R a m s e y L a k e R o a d , S u d b u r y, O N P 3 E 5 J 1
___ Immune
___ Not immune
nd
Date of 2 dose:
Date:
 (705) 523-7179 
(705) 523-7037
HEALTH SURVEILLANCE SCREENING
2
Each year, HSN Volunteers must either receive an influenza
immunization or wear the appropriate respiratory mask at all times
while working in all HSN facilities throughout the duration of the
st
st
influenza season (November 1 to April 1 ).
Influenza
Date of last vaccine:
________________
Signed Disclosure Form Completed:
Yes
No
Tuberculosis (TB) screening Status:
You are required to have a documented 2-step tuberculosis skin test (TST). A TST involves having a small
amount of tuberculin injected under your skin and then having the results “read” 48-72 hours later. A 2-step
TST means that you have to repeat the two visits again one week later.
1st Step
Date planted:
Date read:
Induration (mm):
2nd Step
Date planted:
Date read:
Induration (mm):
If the TB skin test is 10 mm induration or greater, a chest x-ray is required. X-ray must have been completed within the last 12 months and
the positive skin test must be documented above.
X-ray
Date:
Result:
(attach copy of report to this Health Review Form)
If you received BCG vaccine in the past, please complete the section below. The use of BCG vaccine has varied by province/territory &
country so it may not have been part of your previous immunizations. This vaccine is NOT required immunization for employment
purposes.
BCG (Bacille Calmette-Guérin) vaccine:
Date :
The information above was completed by:
Physician
Nurse
Health Unit
College/University
Name of practitioner (please print): _______________________________________
Signature: ________________________________________________
Applicant:
I, _______________________________________ (please print) agree to release the information above to the
Volunteer Services Department of Health Sciences North. I understand that my Advisor will be allowed to
know my immunity status (immune/non-immune) in accordance with the HSN’s Health Care Worker
Communicable Disease Surveillance program policy and the OMA/OHA Communicable Disease Surveillance
Protocols. I certify that, to the best of my ability, the information provided above is complete and correct.
Signature: ________________________________________ Date: ________________________________
Return completed form to:
HSN Volunteer Services Office
Health Sciences North - Centre Tower Level 2
41 Ramsey Lake Road, Sudbury, ON P3E 5J1
Confidential Fax: 705.523.7037
Confidential when completed
K:\Volunteers\Forms\Application process\Health Surveillance rev.doc