Skip to content
Perth
613-267-6400
Smiths Falls
613-283-6745
Search
Home
About Us
Careers
Services
Client Referral Form
Meals on Wheels
Assisted Transportation
Footcare
Congregate Dining
Home Help/Home Maintenance
Respite
Volunteer Hospice Visiting Service
Grief & Bereavement
Volunteer
Events
News
Contact
Home
About Us
Careers
Services
Client Referral Form
Meals on Wheels
Assisted Transportation
Footcare
Congregate Dining
Home Help/Home Maintenance
Respite
Volunteer Hospice Visiting Service
Grief & Bereavement
Volunteer
Events
News
Contact
Donate
Volunteer Form
Name *
Date of Birth (mm-dd-yyyy) *
Telephone
Cell *
Address *
Email Address *
Is this email personal & private?
Yes
No
Emergency Contact *
Relationship *
Emergency Contact Phone # *
Volunteer Opportunities (Please check areas of interest)
Assisted Transportation
Diner’s Club
Meals on Wheels
Volunteer Hospice/Palliative Care Program
Board Member
EMPLOYMENT/VOLUNTEER HISTORY
Do you speak English?
Yes
No
Do you speak another language?
Yes
No
If yes, please specify language:
What are your special skills/hobbies?
Teaching
Nursing
Cooking
Writing
Music
Drama
Computer
Arts & Crafts
Alternative Therapies
Counselling
Hairdressing
Other skills, please specify:
Do you have any health-related problems and/or physical limitations?
Yes
No
If yes, please specify
Do you possess a valid driver’s license?
Yes
No
Do you have a car at your disposal?
Yes
No
Do you smoke?
Yes
No
If yes, will you refrain from smoking while volunteering?
Yes
No
Do you have a pet?
Yes
No
Why are you interested in volunteering for Community Home Support Lanark County?
How did you hear about volunteer opportunities with Community Home Support?
AVAILABILITY: Time of day preferred
Morning
Afternoon
Evening
How often do you expect to volunteer
Once a week
Once a month
Several times a week
Several times a month
Have you experienced any deaths in your family or those close to you?
Yes
No
If yes, please specify your relationship to the person and when they died
Which area of Palliative Care would you prefer to volunteer?
Home Visiting
In-Patient Care
Overnight Sitting
Education
Fundraising
Are you willing to attend a 36-hour training course to become a Hospice volunteer?
Yes
No
Would you be willing to do regular scheduled drives?
Yes
No
Please note any days you would be regularly available:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Are you willing to drive:
local
long distance
Please specify where you would be willing to drive:
How many times per week would you be prepared to drive?
Type of vehicle(s) available:
car
van
truck
Make/model:
Reference 1 Name
Reference 1 Address
Reference 1 Phone
Reference 1 Email
Reference 1 Occupation
Reference 2 Name
Reference 2 Address
Reference 2 Phone
Reference 2 Email
Reference 2 Occupation
Submit Application
Join us for CHSLC's very first annual Barn Dance Fundraiser! We’re super excited to celebrate with you, so don’t forget to reach out to the office for tickets and all the fun details about this fantastic event!
