LTC Volunteer Form

Title

First Name

Last Name

Email

Home Phone Number

Work Phone Number

Cell Phone Number

Preferred Contact Method

Email

Home Phone

Work Phone

Cell Phone

Preferred Location

Maple Health Centre

Newmarket Health Centre

No preference

Type of Registration

Note: Volunteers must be at least 15 years of age.

Adult (18 years or older)

Youth (under 18 years)

Currently I am (select all that apply):

Employed

Unemployed (seeking employment)

Retired

Secondary School Student

Post Secondary School Student

Other…

Secondary School Name

Post Secondary School Name

Will you be receiving academic credits for your volunteer work?

Yes

No

Required number of hours

Date to be completed by

Contact Name

Relationship

Phone Number