Volunteer Application
Thank you for your interest in supporting Momiji Health Care Society. You have joined a team who
generously share their time, talents and skills to help us reach our goals. We value your time and energy,
as you are a vital member of our organization. We want to build a mutually beneficial relationship in
which you, our valued volunteer, use your strengths, passions and dedication to not only benefit Momiji,
but to positively enhance your own life. Thank you for your support and we look forward to working withyou.
Date: _______________
Last Name: _____________________________ First Name: ______________________________________
Address: ________________________________________________________________________________
City: ____________________________________________Postal Code: _____________________________
Home Phone: _______________________Business Phone: ____________E-mail:_____________________
Youth under 18
Languages:
English: Spoken
WrittenYouth 18-24
Japanese: Spoken
WrittenAdult over 24

Other: Spoken
Written

Skills and Interest: _______________________________________________________________________
Area(s) of Interest in Volunteering:
Is there a particular type of volunteer work in which you are interested? (Please check all that apply).
 Assisting with the Momiji Store Friendly Visiting
Momiji Cafe Friendly Telephone Assurance Church Services-Pastoral Care
 Volunteer Driver Decorating for Events/Holidays
 Receptionist
 Gardening Assisting activities for seniors
 No preference Assisting with Bazaar
 Assisting on outings
 Assisting in shopping Assisting at Congregate Dining Program Assisting with Fund Raising/Organizing Special Events
 Volunteer Translator
Other: ________________________________________________________________________________
Please explain your reason(s) for volunteering with Momiji._______________________________________________________________________________________________________________________________________________________________________________________________________________

Availability:
Dates andTimesDay

Morning
Afternoon
Before 12pm 12pm-5pm

Evening
After 6pm

Specific Times(Optional)

MondayTuesday
WednesdayThursdayFridaySaturday
SundayHow long do you think you will be able to volunteer at Momiji? ___________________________________How did you hear about volunteering with Momiji?
Friend/RelativeNewspaper
InternetPhone Book
Walked by

Presentation
BrochurePosterOther

Person to notify in case of emergency: Someone we can call in the event of emergency
Last NameFirst Name
RelationshipStreet Address
City /Town/Postal CodeTelephone Number/E-mail
References: (Preferably someone with whom you have worked or volunteered- not a relative)
Last NameFirst Name
RelationshipStreet Address
City /Town/Postal CodeTelephone Number/E-mail
Last NameFirst Name
RelationshipStreet Address
City /Town/Postal CodeTelephone Number/E-mailIf accepted as volunteer with Momiji, I will require a letter to verify my volunteer status. Purpose of letter: High school Workfare/Ontario works
 Employment reference Volunteer reference Character reference Other (explain) _________________I understand that I cannot receive a volunteer letter until I am actively volunteering with Momiji.  Yes
I am willing and be able to make a minimum commitment of 6 months to Momiji Volunteer Program yes  no If “no” please indicate minimum commitment possible ________months.
To facilitate my screening as a volunteer with Momiji Health Care Society, I hereby authorize theexchange of information between Momiji Health Care Society and the above listed references.
____________________________________________
Signature of Applicant________________________
Date________________________________________________________

Signature of Witness(All information is kept in strictest confidential)

Date