Name*

First Last

Pronouns

(for example: she/her)

Address*

Street Address Address Line 2 City Province Postal Code

Are you under the age of 18?*

Yes
No

If you are under the age of 18, please enter your parent/guardian's name:

Your parent/guardian may be the same as your emergency contact listed below.

If you are under the age of 18, please enter your parent/guardian contact information:

Phone Number or email address preferred.

Home/Cell*

Work Phone

Email Address*

I prefer to be contacted:

by email
by phone
by mail

Emergency Contact Name:*

Relationship to Volunteer:*

Emergency Contact Information

Phone number preferred

Are you presently employed?

Yes
No
Student
Retired

Employer/School Name (optional)

Current Position (optional)

Is there a special reason you have chosen to volunteer with United Way Haliburton Kawartha Lakes? (optional)

Which volunteer assignment(s) interest you?

Please describe

If you ticked "Other" please write in what you would like to volunteer for.

Roughly how many hours per week are you available?

1 - 2 hours
3 - 5 hours
6 - 8 hours
7 - 10 hours
Other

Please describe

If you ticked "Other" please indicate how many hours per week you are available.

What are the best dates/times for your schedule? (select all that apply)

Early Weekday mornings (6:30-8am)
Weekday mornings (9-11am)
Weekday afternoons (1-3pm)
Weekday evenings (5:30-7:30pm)
Early Weekend Mornings (6:30-8am)
Occasional Weekend Opportunities

Are you part of a group/workplace that would like to be scheduled together? (optional)

Please specify

Do you have accessibility recommendations for us to take into account? (optional)

Please specify

Is there anything else you would like us to know about you? (optional)

Would you like to receive United Way HKL’s quarterly newsletter?

By email
By mail
No, thank you

Volunteer Waiver Form

This agreement forms part of and must be attached to the Volunteer Application Form. Before you start volunteering, the United Way Haliburton Kawartha Lakes requires your agreement on the following:

I understand that UWHKL has a volunteer screening process in place, and that I may be asked to undergo an orientation, interview, reference checking, and /or criminal records depending on the nature of the volunteer position for which I am applying.
I recognize that all UWHKL events and services are smoke, tobacco and drug free. In compliance with Provincial and Municipal laws, I will abstain from smoking or using drugs while volunteering for the UWHKL.
I grant permission to the UWHKL to use my name, any photo or video images of me and any comments made by me in writing or otherwise, for promotional purposes in any form of media (i.e. TV, radio, web or print)
I understand that confidentiality is fundamental to all programs of the UWHKL. Volunteers are responsible for maintaining the confidentiality of all proprietary or privileged information to which they are exposed while serving as a volunteer. All volunteers must sign the Statement of Confidentiality form (Appendix B).
I understand that I am representing the UWHKL during my time volunteering and I agree to act in a professional manner at all times. I acknowledge receipt of the Volunteer Code of Conduct and agree to follow it all times while volunteering for the UWHKL
I hereby release and discharge the UWHKL, its agents, employees and licensees from any claim or action that I may have with respect to the use of any of the above or my participation in any related UWHKL activities, while volunteering.

By accepting below, I acknowledge that the information provided is true and accurate and that I have read, understood, and will abide by the Volunteer Agreement above. I grant the UWHKL permission to contact the references listed on my application form and follow up on any information provided.

By ticking this box, I understand and agree to the points mentioned above.

I agree

Committed to Protecting Your Privacy The United Way Haliburton Kawartha Lakes is committed to protecting the privacy and confidentiality of your personal information. The information you provide may be used to assist in the proper administration and acknowledgement of your gift in time, and to periodically send literature on United Way, or to invite you to events and/or information sessions and/or to fulfill your information requests with expressed permission. If you have any questions please do not hesitate to call 705-878-5081. Our Charitable Registration number is 105454508RR0001.

Edwin Binney Waiver

If you are Volunteering for Edwin Binney's Community Garden, please carefully read the following. After you have read and understood the following information, tick the box at the bottom of the page. In consideration for being allowed to work at the Community Garden on the property of Crayola Canada (William E, Coutts, Limited), I hereby indemnify, voluntarily release, hold harmless and forever discharge William E. Coutts, Limited (known as Crayola Canada), and its parents, subsidiaries and affiliates and the United ay Haliburton Kawartha Lakes, as well as any and all of their agents, employees, officers, directors, successors, and assigns (“Releases”), of and from any and all claims, demands, injuries, disability, death, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or in equity, that I ever had or may have, arising from or in any way related to my participation in the community garden, including consumption of the products grown in the garden. This waiver does not apply to any acts of gross negligence, or intentional, willful, or wanton misconduct of the Releasees. This Waiver is binding upon me, my heirs, executors, legal representatives, successors, and assigns. The provisions of this Waiver will continue in full force and effect even after the termination of the activities, whether by agreement, by operation of law, or otherwise. This Waiver contains the entire agreement between the parties, and supersedes any prior written or oral agreements between them concerning the subject matter of this Waiver. I have had sufficient opportunity to read this entire waiver. I have read and understand the terms of this Waiver and I agree to be bound by its terms and have voluntarily signed it as my own free act.

Volunteer Signature

By ticking this box, I am signifying that I understand and agree to the points mentioned above as laid out on behalf of Crayola Canada.

I agree

Volunteer Form

Volunteer Waiver Form

Edwin Binney Waiver