Name: Fall Programs Begin (M/W)
Start: 2019-09-30T00:00:00-04:00
End: 2019-09-30T23:59:59-04:00

Please note, all program volunteers working with children must have a current Police Vulnerable Sectors Clearance (PVSC) valid within one year prior to the start of the program.

Upon request, if you do not currently possess a PVSC, LDANR office staff may provide you with a letter to present to your local police station to apply for the clearance. To apply, you must bring with you two pieces of government issued identification. If you are not a resident of Niagara, but have a temporary Niagara address, you must also bring with you proof of address (e.g., proof of lease, utility bill etc.). Please note: There is a small fee to obtain a volunteer PVSC. Click here for more information on applying for a vulnerable sectors check.
Name*
First Last
Email*
Phone*
Address
Street Address Address Line 2 City Province Postal Code
Date of Birth*
Method of Transportation*
- Bus/City Transit
- Own vehicle
- Dropped off
Availability*
Please indicate the days and times during the week that you are available.
Day of the week Time

References
Please provide the names and contact information for 2 references. *Please note, family members cannot be used as references.*
Name of Reference
Relationship (i.e. supervisor, manager, etc.)
Contact Information (email & phone number)
Name of Reference
Relationship (i.e. supervisor, manager, etc.)
Contact Information (email & phone number)

Terms and Conditions*
1. I hereby agree to comply with the Learning Disabilities Association of Niagara Regions policy on violence and harassment. This is with the understanding that non-compliance may result in my removal from LDANR programming.
2. I understand that the information collected on this form will only be used to assess my eligibility for the position. This information will only be shared with LDANR staff.
3. I give permission to Learning Disabilities Association of Niagara Region to contact the persons listed as my references for the purpose of obtaining reference information. These persons are aware that LDANR may contact them and have my permission to discuss information regarding my current and/or previous employment.
- I have read and agree to the above terms and conditions.
Please type your name in the space below as your signature that you have read and agree to the above terms and conditions:*
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Volunteer Intake Form

Program Selection

Day of the week	Time