Epilepsy South Eastern Ontario 920 Princess Street Kingston, ON K7L 1H1 613-542-6222 www.epilepsyresource.org

Volunteer Registration Form

Volunteer Contact Information:

Name:

Male	Female

Address:

Home Number:

Cell Number:

Email:

Volunteering With Us:

In which areas are you interested in volunteering?

Board Member

Assisting with updating and maintaining our website

Assisting with providing educational workshops/information displays

Assisting with the Grade 5 Thinking About Epilepsy Program

Assisting with organizing our Special Events (i.e. Purple Day for Epilepsy in March, Fire Truck Pull in July)

Office Assistant (mail-outs, organization, filing, ordering office supplies etc.)

BINGO (attending one or more BINGO sessions a month) training provided

Peer Supporter

Regularly: Once a week or more

Occasionally: As Needed

Once a Month

Projects: one to three Months

Special Events

Other

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Mornings
Afternoons
Evenings After 5pm

Emergency Contact Information:

This following information will be kept on file and the individual listed below will only be contacted in case of emergency while you are volunteering with the Epilepsy Resource Centre.

Name of Emergency Contact Person:

Relationship to you:

Home Number:

Work Number:

Do you have any medical concerns we should know about? (ex: Allergies)

Tell Us About Yourself:

What skills and/or talents can you bring to the Epilepsy South Eastern Ontario?

What skills or experience would you like to gain while volunteering with us?

What are your interests or hobbies?

Where have you volunteered in the past?

References:

We request that all volunteers provide us with two personal or professional references that we may contact. We will only contact these references in regards to your volunteer registration with us.

Name:

Phone:

Email:

Company/Title:

Relationship to you:

Name:

Phone:

Email:

Company/Title:

Relationship to you:

Signature of Applicant:

Date:

Thank you for your interest in volunteering with us!