Step 1 of 5 20% Name* First Last Email* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*Cell PhoneDate of Birth*Method of Transportation SchoolProgramClass Requiring PlacementNumber of Placement Hours RequiredStart Date End Date Placement Coordinator Name* First Last Placement Coordinator Email* Placement Coordinator PhoneAvailability (Check the days you are available) Monday Morning Monday Afternoon Monday Evening Tuesday Morning Tuesday Afternoon Tuesday Evening Wednesday Morning Wednesday Afternoon Wednesday Evening Thursday Morning Thursday Afternoon Thursday Evening Friday Morning Friday Afternoon Friday Evening Saturday Morning Saturday Afternoon Saturday Evening Sunday Morning Sunday Afternoon Sunday Evening Please indicate your program of interest.Programs* Reading Rocks (Gr. 2-10) Reading Rocks Junior (Kindergarten-Gr. 1) Let's R.E.A.D. (Gr. 2-4) S.L.A.M. Summer Camp (6-10 yrs) B.E.S.T. Social Skills Program (6-11 yrs) S.M.A.R.T. Math Program (Gr. 2-3) Please indicate your location of interest St. Catharines Thorold Welland Fonthill Beamsville Niagara Falls Port Colborne Fort Erie Niagara-on-the-Lake Briefly outline your placement requirementsWhat is your educational background?Briefly describe your employment historyHave you had previous experience as a volunteer or placement student? If so, with what other organizations, and what kind of work did you do? What are some of your strengths and weaknesses?StrengthsWeaknessesIs there any other information that you would like to provide?What do you hope to gain from your placement with LDANR? ReferencesPlease provide the names and contact information for 2 references.NameRelationship (i.e. supervisor, friend, parent, etc.)Contact InformationNameRelationship (i.e. supervisor, friend, parent, etc.)Contact Information
