Simcoe Muskoka District Health Unit Barrie Office
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COVID19 Immunization Clinic Volunteer Application Form

Please note required fields are marked with an * Asterisk.

Personal Information

Format: i.e. #, Street, City, Postal Code. Enter N/A if you would like to skip this field
Format: ###-###-####

About You

Are you currently a firefighter or first responder?

Have you previously worked or volunteered for SMDHU?

* Preferred clinic locations within SM district:
Check all that apply





Availability (Check all that apply)

Weekdays


Weekends

Police Record Check

* Have you ever been convicted of a criminal offence for which you have not received a pardon?

Volunteer placement offers are conditional upon providing an acceptable Criminal Reference Check as soon as possible.

References
Provide two references other than family.

Format: ###-###-####


Format: ###-###-####

Privacy Statement:

Personal information is collected under the statutory authority of the Occupational Health and Safety Act and Health Protection and Promotion Act. Personal information on this form will be used to determine eligibility for volunteer opportunities and communication regarding any resulting COVID19 Vaccination Clinic volunteer engagements with the Simcoe Muskoka District Health Unit, as well as program evaluation and assessment.

Declaration:

Please read carefully before checking off the box below:

* By checking this box I hereby certify that all of the information that I have provided in this application is accurate and true and I understand that any false or misleading statements or deliberate omissions made by me on this application or during the volunteer recruitment and selection process may be sufficient cause for the cancellation of this application and, if I have been placed in a volunteer position, for the immediate termination of my volunteer placement at the Simcoe Muskoka District Health Unit.

* Required
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