Volunteer Application Form

Fields marked with an asterisk (*) are required.

First Name : *

Last Name : *

E-mail: *

Address : *

Unit Number :

City: *

Country : *

Province: *

State: *

Province/ State : *

Postal Code: *

Phone Number: *

Date of Birth:

Are you presently a student? : *

No
Yes

STUDENT VOLUNTEERS

Steps to follow to become a student volunteer at St. Mary's Hospital Center.

Fill in the application form and print a copy.
Attach to your application form two (2) reference letters. Original, signed reference letters must be dated within the last 12 months. The referees cannot be family or personal friends.
Mail or deliver these documents to :
St Mary's Hospital Center
Volunteer Program (Students)
SB 217
3830, rue Lacombe
Montreal, QC H3T 1M5
If all of the documents are in order and you have respected the dates for submitting the form and letters (see below), you will be contacted for an interview.
There is a limited number of volunteer positions available each session, so applications will be handled on a first-come first- served basis.
You must attend an Orientation Session for in-coming volunteers.
You are expected to contribute a minimum of 3 hours per week for at least 4 months, with the possibility of continuing.
Letters of attestation for your volunteering are available, upon request, after completing 50 hours of volunteer work.

NB: The minimum age for volunteering at St. Mary's Hospital is 18.

The recruitment periods are:

• Summer	April 15-30
• Fall	August 15-30
• Winter	January 1-15

Language(s) spoken: *

English
French
Other

Language(s) written: *

English
French
Other

Reasons for Volunteering:

Helping patients
Academic requirement
Interacting with the public
Supporting the staff
Learning

Interests:

Accompanying patients
Administrative work
Recreational activities
Clerical Work
Friendly visiting
Fund-raising activities

Other:

Special skills (music, arts, computers):

In case of emergency notify :

First Name :

Last Name :

Relationship :

E-mail:

Work Phone :

Home Phone :

Please supply two personal references (other than family):
Reference #1

First Name :

Last Name:

E-mail:

Work Phone:

Home Phone:

Reference #2

First Name :

Last Name:

E-mail:

Work Phone:

Home Phone:

Do you have any problems or restrictions which may affect your volunteer work?

No
Yes

Have you ever been convicted of any penal or criminal offense connected with your proposed volunteer work?

No
Yes

How did you hear about our volunteer program?

Work Experience :

Volunteer Experiences:

Do you have any health problems, psychiatric problems or restrictions which may affect your volunteer work?:

Area of work interest :

Time available (please check at least one) :

	Morning	Afternoon	Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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News Headlines

Governor General's Caring Canadian Award Goes to SMHC Volunteer Ann Kosiuk
April 7, 2009
SMHC 2013 Nursing Awards of Excellence
June 11, 2013
SMHC Family Medicine Centre Annual Scientific Day
May 27, 2013

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