Volunteer Form

Please note that all fields with an asterisk * are required.

* First Name

* Last Name

* Address

* City

* Province

* Postal Code

* Country

* Phone

* Email

* Birth Date

* Emergency Contact Name

* Emergency Contact Phone

What referral source prompted you to contact us?
Lawn SignAcquaintanceNewspaperCommunity Listings Website (e.g., The Londoner, The London Free Press, Southwest Healthline, etc.)Other (Please indicate):

Intended mode of transportation
CarCity TransitOther (Please indicate):

Present occupational status and background (check all that apply)
RetiredStudentEmployed Part-TimeEmployed Full-Time

* Do you speak any other languages besides English?
NoYes (Please indicate):

* Do you belong to any community organizations?
NoYes (Please indicate):

* Do you have any previous volunteer experience?
NoYes (Please indicate):

* Do you have any work experience, education or training with seniors?
NoYes (Please indicate):

Opportunities

We have several areas where volunteers are utilized. What interests you? (check all that apply)

Long-Term Care Program – Seven days a week; mornings, afternoons and evenings:
Recreational Activities and EntertainmentOne-on-One VisitingAssisting Residents to and from Medical AppointmentsMealtime AssistanceAssistance with Saturday TeaPet VisitingPastoral Care Services/VisitsAdministrative AssistanceSpecial Events/Bus TripsArt TherapyTuck ShopHair Salon PorterPalliative CareGardening

McCormick Dementia Services Program – Seven days a week; mornings, afternoons and evenings:
Recreational Activities and EntertainmentGardeningArt TherapyAdministrative Assistance

Please list any other skills or interests not listed above.

(e.g., music, baking, card or chess games, etc.)

* What day(s) and time(s) are you available to volunteer?

(We have volunteer opportunities seven days a week during mornings, afternoons and evenings.)

Are there any limitations or restrictions we need to be aware of?

(i.e. health problems, transportation, etc.)

Photo Agreement Policy

Occasionally, we take photos of our various events and services. Photos are often used as an important resource that enables us to promote the many activities that take place at McCormick Home, McCormick Dementia Services and McCormick Care Foundation and help us to raise awareness of our programs and enhance our community support. Your support of this activity is important to us; however, we respect your wishes.