Volunteer Intake Form

Thank you for your interest in a volunteer position with the Learning Disabilities Association of Niagara Region (LDANR)! Please complete the questions outlined in this form. Once your form is received, a LDANR staff member will be in touch.
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
How did you hear about the LDANR?*
- Flyer/Brochure
- Family/Friend
- LDANR Communication (email, website, etc.)
- Teacher/Professor

References
Please provide the names and contact information for 2 references.
Note: Family members cannot be used as references.
Name of Reference #1
Relationship (i.e. supervisor, manager, etc.)
Email
Phone
Name of Reference #2
Relationship (i.e. supervisor, manager, etc.)
Email
Phone

Terms and Conditions*
1. I hereby agree to comply with the Learning Disabilities Association of Niagara Region (LDANR)'s policy on violence and harassment. This is with the understanding that non-compliance may result in my removal from my LDANR volunteer position.
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 the LDANR to contact the persons listed as my references for the purpose of obtaining reference information. These persons are aware that the 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:*

Program Volunteer

Day of the week	Time