Volunteer Application Form
This form is also available to be filled out electronically at www.autismontario.com/uppercanada
For further information, please contact us at 1-877-268-2211, or via email at autismcornwall@gmail.com
Thank you for your interest in volunteering with the Upper Canada Chapter of Autism Ontario.
Our chapter would not exist without the support of volunteers.
Our chapter serves families in Cornwall and the following counties: Stormont, Dundas, Glengarry, Leeds, and Grenville.
Please fill in the info in the text boxes, “save as” Volunteer_Application_yoursurname and email to
autismcornwall@gmail.com Please mail a signed copy to:
Volunteer Recruitment Team
Autism Ontario
Upper Canada Chapter
P.O. Box 343
Cornwall, ON
K6H 5T1
Section A – Contact Information
Name:
County:
Address:
City:
Province:
Phone (day):
Postal Code:
Phone (other):
Email:
Would you like to be added to our email distribution list to receive news and updates from Autism Ontario and Upper Canada Chapter? Your
email and personal information will not be shared with any other organization.
Yes
No
In case of emergency, please contact:
Name:
Phone:
Section B – Getting to Know You
1. How did you hear about Autism Ontario?
2. Why are you interested in volunteering with Autism Ontario?
3. What would you like to contribute as a volunteer at Autism Ontario?
4. What would you like to gain from your volunteer experience?
5. Are you presently a volunteer with another organization? If yes, please specify the organization, role, and length.
of time
6. What work/volunteer experience have you had that you think might be useful?
7. Do you have language skills in a language other than English?
Speak:
Read:
Write:
Section C – Availability
When would you usually be available to volunteer:
Days
Mornings
Afternoons
Evenings
Days of the week you are usually available to volunteer:
Mon.
Tues.
Wed.
Thurs.
Fri.
How much advance notice would you need to volunteer?
a few days
a week
more than a week
Sat.
Sun
Section D – References
Name:
Relationship:
Phone:
Phone (alternate):
Name:
Relationship:
Phone:
Phone (alternate):
Section E – Permission and Release
1. The references I listed may be contacted for the purpose of processing my application to become a volunteer with
Autism Ontario. I understand that these references will be contacted in confidence;
2. I am in no way obligated to perform any volunteer services for Autism Ontario;
3. I understand that I may be required to undergo a Vulnerable Sector Screening check, if the position involves working
with vulnerable individuals;
4. I acknowledge and accept that this application does not guarantee acceptance to a volunteer role, and that Autism
Ontario is under no obligation to accept me as a volunteer, and is not obliged to provide a reason;
5. I hereby release and forever discharge Autism Ontario, and their employees, directors, volunteers and contract staff
from any cause or claim for damages, whether bodily injury, death, property damage, or emotional trauma, anxiety or
distress arising from my association with Autism Ontario.
6. I give permission to Autism Ontario to share any information that I’ve given them, pertinent to my application to
volunteer, with appropriate staff and volunteers. I understand that if Autism Ontario – Upper Canada Chapter should
cease operation, my file becomes property of Autism Ontario’s Provincial Office.
7. If I am under 18 years of age at the time of my application, my parent/guardian will complete a consent form on my
behalf.
Name (print):
Signature:
Date:
Name of Parent/Guardian (if under 18 years):
Signature of Parent/Guardian:
Date:
What can you do?
Check all of the items that apply. If completing on computer and returning via email, then highlight the item. Please note
that this is not a commitment, simply an indication of your comfort level. These activities / positions do not involve
contact with minors or vulnerable individuals, with the possible exception of those identified by *
__ solicit donations (cash or materials)
__ speak to parents (individually)
__ speak to schools/community groups
__ represent chapter at events
__ write/research grant proposals
__ take good photographs
__ promote events
__ speak to the media
__ compile info on community agencies & services
__ check web links
__ organize and help with chapter events
__ communicate with government representatives
__ write or produce awareness materials
__ Together for Autism coordinator for chapter
__ be a SEAC representative Board:
__ organize or help with fundraising activities *
__ organize or help with information activities
__ organize or help with family social activities *
__ organize activities for siblings (SibShops) *
__ organize social skills group activities *
__ organize parent get togethers
__ communicate with community organizations
__ communicate with local law enforcement
__ camp administration
__ write newsletter articles
__ set up displays at chapter events
__ participate at provincial level
__ handle finances
__ resource coordinator
(other – please let your imagination run free!)
What do you know about?
__ the special education system
__ ABA/IBI
__ setting up a home-based programs
__ nutrition
__ augmentative communication (PECS, sign language)
__ auditory integration
__ social stories
__ occupational therapy
__ physical therapy
__ respite
__ financial/estate planning issues
__ housing issues
__ employment issues
__ integration/inclusion strategies for education
__ VB (Verbal Behaviour)
__ biomedical/DAN protocol
__ adaptive technology
__ speech therapy
__ social skills
__ visual schedules
__ sensory integration
__ Floortime
__ funding alternatives
__ post-secondary education issues
__ sexuality issues
__ (other – please specify)
Are you interested in provincial-level activities?
Opportunities to participate on provincial-level committees or consultation groups arise during the year. It is impossible
to predict what kind of opportunities will arise or what kind of commitment they will require, nor is there any obligation
for us to participate. The chapter reimburses travel expenses.
Yes - I’m interested in hearing about provincial-level activities.