Literacy Council York-Simcoe
Volunteer Application Form
Literacy Council York-Simcoe (LCYS) respects the privacy of our members, clients, volunteers, staff, donors, sponsors and
stakeholders. We are committed to ensuring that appropriate measures and safeguards are in place to protect specific
information that is held for the purpose of the program. We adhere to all legislative requirements with respect to privacy. We
do not rent, sell or trade mailing lists. This information will be treated as confidential and will not be released without your
permission.
Contact Information
Date:
Name:
Home Phone:
Address:
Work Phone:
Cell Phone:
City:
Fax:
Postal Code:
Email:
Transportation: (car/bus etc.)
Employer:
Date of Birth: (statisical purposes only)
How would you like to be contacted?
Home
Work
Do you give permission to LCYS to share your phone number with your student?
Cell
Email
Yes
No
Please check the areas where you would be interested in volunteering for the council:
Tutor
Board member
Trainer
(for tutors)
Office Help
What is your level of education?
How did you find out about our agency and this volunteer opportunity?
Please describe your occupation or area of work experience.
Please describe other relevant jobs or volunteer experience.
What hobbies or interests do you have?
Fundraising
Marketing/Promotion
Availability
We ask our volunteers to commit to a minimum of two hours per week for at least 12 months. Volunteers meet
with their learners once a week. Please indicate when you think you'll be available.
Mon
Tues
Wed
Thurs
Fri
Morning
Afternoon
Evening
9am-12pm
12pm-5pm
5pm-9pm
shaded areas = office is closed
If you have indicated you are interested in volunteering in other area within the council please specify
Subjects and Levels
We tutor learners who range in skill level from grade K to 10+ (Level 1-5). Please indicate the level and subjects
you are interested in tutoring.
Reading
Writing
Math
Beginners
Advanced
Grd K-5
Grd 6-10+
approximate skill levels
Other Considerations
Please mention any other information we should consider in matching you with a literacy learner,
for example: allergies, male/female preference, smoker/non-smoker, year round availability etc.
Please answer the following two questions in your own words. We will take both the information
and the clarity of expression into account in assessing your suitability to become a literacy tutor.
1. The International Adult Literacy Survey (2003) revealed that 42% of adult Canadians do not have literacy skills necessary
to function fully in society.
What, in your opinion, are some of the factors that have caused this situation?
2. Please explain why you are interested in becoming a literacy tutor.
Would you submit to a police check, if required?
Yes
No
We will be calling your references prior to you starting your volunteer position.
We will be asking your references about your ability to handle a position of trust.
Please provide a personal and professional reference (if applicable).
References
1
Phone:
Phone:
2
Phone:
Phone:
Release for Reference Checks
gives permission to Literacy Council York-Simcoe to contact the
(Name)
references provided, regarding the application to volunteer with LCYS.
Full name
Date
All of the information that I have provided in this application form is correct.
Full Name
Date
Literacy Council York-Simcoe
Mission Statement
Literacy Council York-Simcoe provides adults in York-Simcoe with the opportunity, tutoring, training and tools to
improve their reading, writing, numeracy computer, and life skills.
LCYS Values
We value professionalism, which ensures information and teaching styles are up to date and appropriate for volunteers and
students.
We value an environment of respect and confidentiality for all.
We value our ability to provide cost-effective training for students and volunteers.
We value out ability to provide individualized training appropriate to the need of the student
We value a supportive and empowering learning atmosphere for volunteers students and the community.
Have you read and understand our mission and values?
Yes
No
Statement of Confidentiality - Please read, to be signed prior to Volunteering
I, the undersigned, do willingly promise to hold in confidence all confidential matters that come to my attention
while involved with Literacy Council York-Simcoe. Matters considered to be confidential include, but are not
limited to: personal information; personal issues; matters of litigation; agency related information regarding
students, volunteers and staff of LCYS. I agree that any information that I gain will be used in a responsible
manner, and only in relation to my responsibilities with LCYS during my time with LCYS or any time thereafter.
Signature:
Date:
Witness:
Waiver - Please read, to be signed prior to Volunteering
In consideration of accepting this assignment, I hereby for myself, my heirs, administer and assigns waive and
release any and all right and claim for damages against Literacy Council York-Simcoe, Board of Directors, staff,
volunteers and any association connected with it, their successors and any and all injuries by/to me during my
involvement with the Literacy Council York-Simcoe.
Signature:
Date:
Witness:
Submit after Completion
November 2013