Volunteer Application Form Volunteer Application Name * Required First Last Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Phone * RequiredSecondary PhoneHow do you prefer to be contacted?PhoneEmailAre you 18 years of age or older?YesNoEmergency ContactEmergency Contact Name * Required First Last Emergency Contact Phone * RequiredEmergency Contact Email Relationship: AvailabilityPreferred times for volunteering. * Required Monday Morning Monday Afternoon Monday Evening Tuesday Morning Tuesday Afternoon Tuesday Evening Wednesday Morning Wednesday Afternoon Wednesday Evening Thursday Morning Thursday Afternoon Thursday Evening Friday Morning Friday Afternoon Friday Evening I am only available on weekends. Skills and InterestsYou are welcome to upload your cover letter and/or resume here. Drop files here or Select files Accepted file types: doc, docx, pdf, jpg, png, gif, Max. file size: 10 MB, Max. files: 3. Maximum file size - 10 mega bytes. Indicate which volunteer activities you are interested in Support Line Friendly Callers Do you speak other languages besides English? If you proficiently speak French, please describe the level of capacity that you have to assist French speaking individuals we serve.List training or certifications that you have:Have you volunteered with a CMHA Middlesex, WOTCH Mental Health Services or My Sisters' Place program before? * Required Yes No Previous Experience (Paid and Volunteer)Previous Experience * RequiredOrganizationDutiesFrom (MM/YY)To (MM/YY) Please list past paid or volunteer experiences.ReferencesPlease provide three references. One must be a professional reference.References * RequiredReference NameAddressPhone NumberEmail AddressRelationship AcknowledgementDeclaration * Required I agree I declare that the information provided in this application is truthful, complete and correct. I authorize the Canadian Mental Health Association Middlesex to contact individuals or organizations I have named on this application to obtain further information that would assist with my placement as a volunteer. The information on this application form is collected under the authority of the Freedom of information and Protection of Privacy Act, and will be used solely for the purpose of determining eligibility and suitability for volunteer opportunities.UntitledFirst ChoiceSecond ChoiceThird Choice
