Volunteer Application

Thank you for your interest in volunteering with Palliative Manitoba. We accept applications on an ongoing basis for the next available course.

Individuals who wish to volunteer for Palliative Manitoba must first complete the Volunteer Application Form (below). Individuals that fulfill the screening requirements will be invited to attend the eight-week Compassionate Care Course. Once selected, volunteers are asked to consent to a minimum one-year post-course commitment.

You can download, print and complete the application manually or submit via the online form below.

Volunteer Application Form (PDF)

Volunteer Application Form

Last Name: *
First Name: *
Middle Name:
Preferred Name: *
Address: *
City/Town: *
Province: *
Postal Code: *
E-mail:

Phone:

Home:

Business:

Cell:

I prefer to receive communications at: *
HomeBusinessCellE-mail
Best time:

Education

High School

Name of Institution:

Level of Educ. :

Post-Secondary

Name of Institution:

Level of Educ. :

Professional Training

Name of Institution:

Level of Educ. :

Trade or Business

Name of Institution:

Level of Educ. :

Other

Name of Institution:

Level of Educ. :

Education: Formal education is not required to be a volunteer. We welcome experience of all kinds!
Preferred Language: *
Other Languages:
Are you receiving credit for your volunteer work? *
YesNo
Required number of hours:

Employment History

Employment Status: *
Employed F/TEmployed P/TRetiredUnemployed
Last three places of employment:

Employer 1

Company Name / Employer:

Job Title:

From:

To:

Reason for Leaving:

Employer 2

Company Name / Employer:

Job Title:

From:

To:

Reason for Leaving:

Employer 3

Company Name / Employer:

Job Title:

From:

To:

Reason for Leaving:

Volunteer History

Health Information

Please list any limitations, or health issues (include allergies, back problems, etc.) which may affect your ability to perform volunteer duties and that you wish to have taken into consideration when pursuing a volunteer placement.

Emergency Contact

Name: *
Relationship: *

Phone

Home:

Work:

Cell:

References

Please list three references—past or present employers, volunteer administrators, teachers, etc. One reference from a personal friend is acceptable (this does not include family).

Reference 1

Name:

Connection:

Phone Number:

Reference 2

Name:

Connection:

Phone Number:

Reference 3

Name:

Connection:

Phone Number:

Personal Information

1. Have you experienced any losses in your personal life? (Death, divorce, health issues, etc.) And how recently were the losses? *
2. What kind of experiences in your work with PMb might be upsetting to you? *
3. Is there a time in your life when you needed to turn to someone for help or support? (Need not have been a professional) *
4. Describe how it felt to approach this person. *
5. What did you see as helpful? *
6. Was there anything that was not helpful? *

7. What do you feel are the:

Strengths that you bring to your volunteer work? *

Weaknesses that you bring to your volunteer work? *

Disclaimer

Because Palliative Manitoba takes its responsibility for clients and services seriously, we screen all our applicants thoroughly. While we try to accept every prospective volunteer, PMb reserves the right to reject any applicant.
I hereby certify that all information in this application form is true and complete.
I hereby authorize Palliative Manitoba to verify any information supplied by me in this application form to ascertain my suitability as a volunteer. I hereby release Palliative Manitoba from all liability for any damage whatsoever for issuing same. I further authorize Palliative Manitoba to maintain this information in their records and release and absolve them from all liability that may otherwise accrue by reason of their keeping this information and using it for their purpose.
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Email
Email
Email

Verification

Please enter any two digits *Example: 12
This box is for spam protection - please leave it blank:

Volunteer Application

Volunteer Application Form

Phone:

Education

High School

Post-Secondary

Professional Training

Trade or Business

Other

Employment History

Employer 1

Employer 2

Employer 3

Volunteer History

Volunteer 1

Volunteer 2

Volunteer 3

Commitment

Health Information

Emergency Contact

Phone

References

Reference 1

Reference 2

Reference 3

Personal Information

7. What do you feel are the:

Disclaimer

Verification