You must have JavaScript enabled to use this form. * Indicates a required field Personal information Surname * Name * Address Date of birth City Province - None -Nouveau-BrunswickNouvelle-ÉcosseÎle-du-Prince-ÉdouardTerre NeuveQuébecOntarioManitobaSaskatchewanAlbertaColombie BritanniqueTerritoires du Nord-OuestYukonNunavut Postal code Telephone Home * Work Cell E-mail * Languages Spoken French English Other Specify Written French English Other Specify In case of emergency, please notify Name Telephone Relationship Experience Profession Sans emploi Étudiant Travailleur Retraité Current job Training Work experience Hobbies, interests Other relevant information Have you ever volunteered in any facility within Vitalité Health Network? You can attach your resumé to this application Do you have a health problem that could affect your availability or volunteering? Why do you want to volunteer? Volunteer opportunities Which volunteer programs interest you most? You can view the list of programs at: http://www.vitalitenb.ca/en/volunteers (Please list in order of preference) : Please specify facility Acadie-Bathurst Zone Enfant-Jésus RHSJ† Hospital Tracadie-Sheila Hospital Lamèque Hospital and Community Health Centre Chaleur Regional Hospital Beauséjour Zone Veterans’ Health Centre Dr. Georges-L.-Dumont University Hospital Centre Shediac Regional Medical Centre Stella-Maris-de-Kent Hospital Northwest Zone Grand Falls General Hospital Edmundston Regional Hospital Hôtel-Dieu Saint-Joseph de Saint-Quentin Restigouche Zone Campbellton Regional Hospital Veterans’ Unit Restigouche Hospital Centre St. Joseph Community Health Centre (Dalhousie) Regional Addiction Services Special Skills Please indicate whether you have any special skills that you would be willing to offer as a volunteer Knitting Sewing Arts and crafts Computer Musical instrument or singing Painting Woodworking Esthetics Hairdresser Other Other References Please provide the name, complete address and e-mail address (when possible) of three persons who know you well and could provide a reference (individuals to whom you are not related and who have known you for at least two years). 1. Name Telephone Address Postal code Relationship E-mail Communication French English 2. Name Telephone Address Postal code Relationship E-mail Communication French English 3. Name Telephone Address Postal code Relationship E-mail Communication French English Availability Please indicate your availability below Sunday AM Sunday PM Sunday Evening Monday AM Monday PM Monday Evening Tuesday AM Tuesday PM Tuesday Evening Wednesday AM Wednesday PM Wednesday Evening Thursday AM Thursday PM Thursday Evening Friday AM Friday PM Friday Evening Saturday AM Saturday PM Saturday Evening Can you, for the most part, volunteer the same day and time once a week? If not, please explain. Have you ever been convicted of a crime for which you have not received a full pardon? If yes, explain. I certify that statements made in this application are true and correct. * I certify Leave this field blank