Volunteer – Chatham-Kent Victim Services

Name*

First Middle Last

Preferred Name*

First

Please list all previous surnames/maiden names

Preferred Pronouns*

Address (please include mailing address)*

Street Address Address Line 2 City Province Postal Code

Birth Date*

Phone (Mobile)

Email*

How did you hear about Chatham-Kent Victim Services and this volunteer opportunity?

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact Relationship*

Do you have access to a vehicle with adequate insurance?*

Yes
No

Are you willing to answer calls and be on-scene within a maximum of one hour?*

Yes
No

If no, please explain (i.e. live outside of CK etc.). This does not disqualify you, but helps us be aware of your limitations in this aspect

Are you willing to travel anywhere within Chatham-Kent?*

Yes
No

Are you able to work with confidential information?*

Yes
No

Have you ever been charged with a criminal offense for which a pardon has not been granted?*

Yes
No

If yes, please explain:

Would you object to a Criminal Background and Vulnerable Sector Check?*

Yes
No

If yes, please explain:

Shift Availability

(please check all that apply)
You are required to commit to a minimum of 48 hours worth of on-call time per month. Shifts are 6 hours (7am - 1pm; 1pm - 7pm) or 12- hours (7am - 7pm; 7pm - 7am). Reminder that being on-call means you are ready, willing, and available to take a crisis call and you may still go about your daily activities as long as you can respond to a call for support within a reasonable time. Shifts are selected on a scheduling system by volunteers on a first come, first served basis.

*

We ask for a commitment of one year as a volunteer. However, we understand circumstances change. How long of a commitment could you realistically make to this service?*

Do you speak a second language?*

Yes
No

If yes, which languages do you speak and would you be willing to use them?

Employment Status*

Length of employment (if applicable)

Current or Last Employer (or school if a student)*

Job Title (or program if a student)*

Highest Level of Education Completed*

Grade School
High School
College
University

Area of concentration

Briefly state why you are interested in becoming a volunteer with Victim Services*

Do you have any personal and/or professional goals related to the work we do at CKVS? (i.e. Want to go into policing, corrections, mental health etc.)*

Do you have any relevant experience in Crisis Intervention, Mental Health, Supporting Vulnerable populations?*

Other training which may be relevant (CPR, workshops, certificates etc.)*

Interests, skills and hobbies*

Present / Previous Volunteer Experience*

Is there any other information that you feel staff should be aware of?*

Please list three references

No family references, we must receive at least two of the three references. References will be contacted through email and asked to reply with a digital reference form.

Reference #1 Name*

First Last

Reference #1 Phone*

Reference #1 Email*

Reference #1 Occupation*

Reference #1 Relationship*

Reference #1 Years Acquainted*

Reference #2 Name*

First Last

Reference #2 Phone*

Reference #2 Email*

Reference #2 Occupation*

Reference #2 Relationship*

Reference #2 Years Acquainted*

Reference #3 Name*

First Last

Reference #3 Phone*

Reference #3 Email*

Reference #3 Occupation*

Reference #3 Relationship*

Reference #3 Years Acquainted*

In making this application, I give permission to Chatham-Kent Victim Services to contact the persons named as references to ascertain my suitability as a volunteer. Also, I realize that a recent police clearance will be required to determine eligibility.

Furthermore, I give Chatham-Kent Victim Services permission to circulate my name to members of the Chatham-Kent Police Service for internal screening purposes. I acknowledge that this volunteer position involves exposure to other people's trauma and traumatic situations.

Signature*

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Shift Availability

Please list three references

If you require support, contact our office at 519.436.6630

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