VOLUNTEER RESOURCES and ENGAGEMENT DEPARTMENT
Step Up Youth Program
VOLUNTEER APPLICATION PACKET
ROYAL JUBILEE HOSPITAL
Step Up and
Courage Aspire Respect Empathy
Step Up and Learn
Step Up and Lead
Program Details:
For Step Up Youth Program information and details, visit:
https://www.islandhealth.ca/volunteer-resources/volunteer-opportunities/step-youth-program
Program Details RJH:
https://www.islandhealth.ca/volunteer-resources/volunteer-opportunities/volunteer-royal-jubilee-hospital
Applicants - Submit Completed Application Package:
Hand Deliver:
RJH
Internal
Location: Royal
Block, Level 4,
Room 453A.
If no one is present,
slide application
under door
Mail:
Attention: Volunteer
Intake
Royal Jubilee
Hospital
Volunteer Resources
Department RB 453A
1952 Bay Street
Victoria, B.C. V8R 1J8
Email:
RJHVolunteerIntake@VIHA.CA
Volunteer Resources: Trusted. Included. Valued.
Volunteer Resources and Engagement
Dear Island Health Volunteer Applicant, thank you for your interest in volunteering with Island Health.
Volunteering in health care is a privilege and a serious commitment. Please indicate your response to
each of the requirements below.
Please send completed document to
Your Name:
Your email address:
Please click on the box next to your chosen response (or place a check mark if the document is printed).
n/a = not applicable
Are you willing to commit at least 60 hours (approximately 6 months) of volunteering?
Typical assignments: 1 shift per week (shift length anywhere from 1.5 4 hours,
depending on assignment); there are some exceptions.
Yes No
Our initial intake process can take 4-6 weeks and includes setting up an interview.
Some sites do periodic intake which may extend this time frame. Will this pose a
problem for you?
Yes No
Online learning is required for all Island Health volunteers.
Applicants for Acute Care Hospital or Community / Inpatient Mental Health &
Substance Use settings: 8 hours of online learning is required. Are you willing to
make this commitment?
Applicants for Residential settings (long term care) or Community Health Units: 2
hours of online learning and 1 hour of additional reading is required. Are you willing
to make this commitment?
Yes
No
n/a
Yes
No
n/a
Are you willing to attend additional site and assignment training?
Yes No
Do you have questions regarding our requirement for a Ministry of Justice Criminal
Record Check, including Vulnerable Sector Verification (both Children and Vulnerable
Adults)? Note: this screening is completed through our department and does not need
to be in place prior to interview.
Yes No
Do you have spoken English (ESL Level 6 preferred)?
Yes No
Do you understand that an email account is required?
I understand
I acknowledge that Island Health strongly recommends staff and volunteers do not
wear: nail polish, long nails, artificial nails, extensions, nail jewelry, or hand or wrist
jewelry (although plain wedding bands and medical alert bracelets are acceptable). I
understand that by following this policy I contribute to improving the health outcomes
for the patients, residents, and clients, as well as protecing my own health.
No
Do you agree to comply with the BC Influenza policy: either have an annual flu vaccine
or wear a mask during flu season (typically December to March) each year?
Yes No
Youth Volunteers: Parent / Guardian consent is required if under 19 years of age.
Will this pose a problem for you?
Yes
No
n/a
These requirements support excellent care and provide you with a good foundation for volunteering in health care.
We appreciate you taking the time to consider whether volunteering with Island Health is the right choice for you.
Site Address:
Volunteer Resources: Trusted. Included. Valued.
Island Health Site:
Yes
Do you agree to update relevant training/certificates annually? (approx. 1 hour)
Yes No
Royal Jubilee Hospital (RJH)
1952 Bay Street, Victoria, BC, V8R 1J8, Royal Block, 453A
Revised: 12/Sep/2019
Page 1 of 4
VOLUNTEER RESOURCES and ENGAGEMENT
VOLUNTEER APPLICATION FORM
Island Health Site:
YOUTH
ADULT
DATE:
FULL LEGAL NAME:
Dr.
Mr.
Mrs.
Ms.
None
Preferred
GENDER:
Male
Female
Non-Binary
2-SPIRIT
__________
PREFERRED NAME OR NICKNAME:
DATE OF BIRTH: (mm/dd/yyyy)
E-MAIL:
PHONE CONTACT::
Indigenous Metis Inuit
ADDRESS:
CITY/PROVINCE: POSTAL CODE:
EMERGENCY CONTACT
NAME:
RELATIONSHIP:
PHONE #:
EMAIL:
PLEASE GIVE TWO REFERENCES NO RELATIVES (E.g.: Volunteer Administrator, teacher, current/former employer) - PLEASE INCLUDE EMAIL ADDRESSES
NAME:
RELATIONSHIP:
PHONE #:
EMAIL:
NAME:
RELATIONSHIP:
PHONE #:
EMAIL:
HOW DID YOU HEAR ABOUT OUR VOLUNTEER PROGRAM?
COMMUNITY/VOLUNTEER EXPERIENCE:
RELEVANT EXPERIENCE:
YOUR SPECIAL SKILLS, INTERESTS, HOBBIES?
LANGUAGES? WRITTEN:
SPOKEN:
WHY ARE YOU INTERESTED IN VOLUNTEERING?
WHAT KIND OF VOLUNTEER ASSIGNMENT WOULD YOU LIKE?
WILL YOU REQUIRE A PARKING PERMIT?
Yes
No
LENGTH OF COMMITMENT:
6 Months
Longer
EMPLOYMENT
FULLTIME
PARTIME
PLACE OF EMPLOYMENT
SCHOOL
FULLTIME
PARTIME
NAME OF SCHOOL
TIME AVAILABILITY: (Please Check)
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
MORNINGS
AFTERNOON
EVENINGS
RJH (Step Up Youth Program)
GENERAL HEALTH STATUS
IMMUNIZATIONS
Island Health recommends all volunteers have a Tetanus and Diphtheria (Td) Vaccine every 10 years. If it has been more than
10 years since your last Td booster it is recommended you do so.
Measles, Mumps, Rubella (MMR) Vaccine is recommended for all volunteers. For all individuals born after January 1, 1970,
two doses of measles-containing vaccine (given as MMR in Canada) are recommended. Individuals born before 1970 are
generally assumed to have acquired immunity to measles from natural infection.
Varicella (chickenpox) vaccine is recommended for all volunteers. Those with a history of chicken pox disease before 2004 are
presumed to be immune and do not need vaccination.
Pertussis-containing vaccine is recommended for volunteers working with young children/infants/pregnant women. This
vaccine is included in a combined tetanus-diphtheria-pertussis vaccine (Tdap) for adults and older children.
FLU POLICY
Pleas
e note that Island Health’s Influenza Policy applies to volunteers. This means that volunteers must be immunized for
influenza during onsite clinics (held in the fall) or through other sources of vaccine such as Public Health Units, pharmacies or
family physicians. If volunteers choose not to or are unable to, they may wear a mask during flu season approx. December 1 to
March 31 annually.
TUBERCULOSIS SCREENING Have you ever had active Tuberculosis? YES NO
Have you been experiencing any of the following symptoms for longer than one month?
Excessive fatigue:
YES
NO Unexplained weight loss:
YES
NO
Persistent cough: YES NO
Coughing up blood: YES NO
Excessive night sweats:
YES
NO
Persistent fever:
YES NO
IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE:
You will need to make an appointment with your family physician to rule out a communicable condition (such as active tuberculosis).
If a TB scratch/skin test is required, you will need to go to the South Island TB Clinic or the nearest Public Health Unit. Inform the
unit that you are planning to volunteer at an Island Health Site. The results of your TB screening will need to be documented below
and returned to your Volunteer Administrator before you may begin volunteering.
TRAVEL
If, after returning from foreign travel, you are experiencing any of the above listed symptoms associated with Tuberculosis, please
notify your Volunteer Administrator that you will need to temporarily discontinue volunteering, and see your doctor. Follow the steps
above underIf you have answered yes to any of the above”.
ADDITIONAL INFORMATION
Do you have any illnesses or conditions that could be transmitted to other personnel or patients during the course of your duties?
YES NO If
yes please describe:
Do you have any conditions or restrictions that would impact your ability to perform your volunteer duties safely?
YES
NO If yes please describe:
I WILL RESPECT CONFIDENTIAL INFORMATION AND THE RIGHTS AND DIGNITY OF ALL PATIENTS AND RESIDENTS.
I WILL HONOUR MY COMMITMENT AS A VOLUNTEER AND PROVIDE ADEQUATE NOTICE OF MY ABSENCES.
I WILL ABIDE BY THE POLICIES AND STANDARDS OF THE DEPARTMENT OF VOLUNTEER RESOURCES.
SIGNATURE OF APPLICANT: DATE:
VOLUNTEER ADMINISTRATOR, or DESIGNATE: DATE:
IF APPLICANT IS A YOUTH
(UNDER THE AGE OF 19), PARENTAL CONSENT IS REQUIRED. PLEASE SIGN BELOW:
NAME (PLEASE PRINT): DATE: SIGNATURE OF PARENT OR GUARDIAN:
Revised: 12/Sep/2019
Page 2 of 4
VOLUNTEER RESOURCES -
RJH (Step Up)
Revised: 12/Sep/2019
Page 3 of 4
VOLUNTEER RESOURCES -
STATEMENT OF UNDERSTANDING
Please read these next two pages carefully. Your signature at the end indicates you have read, understand and
agree to each of the following statements.
I, _ agree to serve as an Island Health Volunteer, and attend regularly and
perform my volunteer service to the best of my ability and according to the guidelines provided by Island Health
Department of Volunteer Resources. I will meet the time commitments, or provide adequate notice so that
alternative arrangements can be made. I will act at all times as a contributing member of the health care team
towards accomplishing the mission of Island Health.
PERMISSION TO PERFORM A BACKGROUND CHECK
I give permission for the VIHA Volunteer Resources Departments to perform a check of my background,
which may include:
criminal record check, including a vulnerable sector check
driving record
past employment and/or volunteer history
personal references
other persons or sources as is appropriate for the volunteer service(s) in which I have expressed an interest
I understand that information collected during this background check will be limited to that which is appropriate to
determining my suitability for the particular types of volunteer service in which I will be involved. I understand that
all information collected during the check will be kept confidential.
I unde
rstand that:
Information collected through registration will be stored electronically and used for management functions
by the Volunteer Resources and/or Spiritual Care and/or Auxiliary Departments within Island Health
All Island Health volunteers will be required to have official Island Health photo identification
From time to time, pictures may be taken for publicity and display purposes (examples below):
* Displays Videos Local Community Newspapers * *
Volunteer Resources or Island Health Websites VIHA publications* *
STANDARDS OF CONDUCT, RESPECTFUL WORKPLACE AND ACCEPTABLE USE OF ASSETS POLICIES
These policies have been provided to you and/or can be found on the Island Health website at
Policies for
Volunteers
.
If you do not have access to a computer,
please note you will be given a copy of the policies to read
at the interview and/or orientation.
I (print name) hereby acknowledge that I have read and understood the
following Island Health's policies: (Click on each link to view and read the policy)
-
Respectful Workplace Policy
-
Island Health Volunteer Resources Standards of Conduct
-
Acceptable Use of Assets and Resources Policy
PERMISSION TO TAKE PHOTOGRAPHS AND TO STORE REGISTRATION or PERSONAL INFORMATION
ELECTRONICALLY
RJH (Step Up Youth Program)
Revised: 12/Sep/2019
Page 4 of 4
VOLUNTEER RESOURCES -
REQUESTS FOR REFERENCE
Educational institutions and employers recognize the value of volunteer experiences.
I understand that the Freedom of Information and Privacy Protection Act prohibits Island Health from giving
references without my written approval. I hereby give permission to Island Health’s Volunteer Resources
Departments to provide references, written and verbal, related to my volunteer service. I understand that a
reference may only be provided after 60 hours of volunteer service and/or at the discretion of the site’s Manager,
Volunteer Resources.
INFECTION CONTROL RISKS
I unde
rstand that as a volunteer with Island Health there are risks associated with being in a facility and on
a unit or ward. As I will be volunteering in a health care setting, these risks include possible exposure to
communicable diseases. I will be aware of these risks and as a volunteer keep updated on training and
safety procedures that could impact my position. I am aware that I might be asked to have additional testing
(e.g. TB) if it is warranted, and vaccinations, (e.g.: Influenza Virus) in order to carry out my duties as a
volunteer safely. If I am unsure of a potential risk, I will ask my Manager for clarification.
EDUCATION
You will be required to take courses that are part of Island Health’s on-line Learning Management
System (LMS)
available to volunteers as well as staff. When you use the Course Catalogue Registration System
(CCRS) within LMS, Island Health/VCH/PHC/FHA* collects personal information about you, such as your education
profile, the date and time you accessed the system and also your grades for any quiz or other assessment. Course
managers and your direct supervisor may access your user history to confirm that you achieved a passing grade on
any course offered through CCRS. Your personal information is collected and used for the purposes of managing
educational opportunities and requirements for your affiliation with Island Health/VCH/PHC/FHA. Island
Health/VCH/PHC/FHA collects, uses and shares personal information only in accordance with the BC Freedom of
Information and Protection of Privacy Act.
* VCH = Vancouver Coastal Health; PHC = Providence Health Care; FHA = Fraser Health Authority
EMERGENCY AND DISASTER PLANNING
I agree to be included on a contact list in the event of a disaster or emergency to provide assistance
during a response. I understand that I may not be contacted, and that I may be able to help without
waiting to be contacted.
If you agree to the above, please indicate if you have any disaster management training or experience:
I understand that my contact information may be shared with Island Health staff and other volunteers
for purposes related to orientation, training, scheduling and other volunteer management functions.
I AGREE TO ALL OF THE ABOVE: (unless otherwise stated on this form)
Signature: _
Date: / /
Month Day Year
RJH (Step Up Youth Program)
VOLUNTEER RESOURCES & ENGAGEMENT - ________________
REFERENCE QUESTIONNAIRE
(This form is to be completed by two references)
Volunteer Name: ___________________________________________ Date: ____________________________
Please answer the questions regarding this prospective volunteer’s personality, character and qualities for
volunteering at __________________________. All information you share helps us find the right volunteer
placement for this person. The volunteer listed will be supporting staff and/or providing a social support to the
residents/patients and their loved ones at __________________________.
QUALITY
NOT
KNOWN
AVERAGE
BELOW
AVERAGE
ABOVE
AVERAGE
EXCELLENT
1. Reliability, commitment
2. Trustworthy, hones/Integrity
3. Ability to communicate and
be understood
4. Interpersonal skills, working
with others
5. Conflict resolution skills
6. Respectful/considerate
of others
7. Able to take direction
8. Good common sense
9. Good boundaries
10. Overall personality/character
PLEASE ANSWER THE FOLLOWING
YES
NO
COMMENTS
Is the applicant a suitable candidate?
Does the applicant require supervision?
Do you feel the applicant’s other commitments may interfere
with his/her commitment to volunteering?
Any further comments:
Reference Name: ________________________Relatio
nship to the applicant:___________________________
Phone or email:___________________________ Reference Signature:__________________________________
*
Please note an original signature is required unless this form is filled out online and sent from the referencespersonal email. The personal
email will be cons
idered a valid signature.
Please email, mail or drop off completed form to: Volunteer Resources & Engagement, Attention: RJH Intake
Email: ___________________________________________,
Mail/drop:________________________________________________________, _____________, BC, ________
Your reference is important and appreciated. Thank you.
RJH (Step Up)
Revised: Sept 3, 2019
RJHVolunteerIntake@VIHA.CA
Royal Jubilee Hospital, 1952 Bay St. Royal Block 453A
Victoria
V8R 1J8
1 | Page
VOLUNTEER RESOURCES AND ENGAGEMENT DEPARTMENT
High School StudentsStep Up Youth Program Applicants Ages 14 to 18 Only:
TO BE COMPLETED BY TEACHER, COACH, OR SCHOOL COUNSELLOR
NAME OF YOUTH APPLICANT: _______________________________________________
The applicant wishes to be a Youth Volunteer in our hospital. We require a minimum sixty-hour commitment
over six months of approximately two hours per week.
If the youth is signing up for the Step Up program, they will be enrolled in the program from September
through to April in the school year.
The information you provide is confidential. Your comments will give us a better understanding of the
applicant’s background and character. I would appreciate any information or comments you consider
important to this application. Thank you for your prompt response.
PLEASE ANSWER THE FOLLOWING
YES
NO
COMMENTS
1. Is the applicant a suitable candidate?
2. Is the applicant reliable?
3. Is the applicant considerate of others?
4. Does the applicant work well with others?
5. Does the applicant require constant supervision?
6. Do you feel the applicant’s school work would
suffer through participation in this program?
COMMENTS:
________________________________________________________________________________________
________________________________________________________________________________________
PRINT NAME: _______________________________ POSITION: __________________________
WRITTEN SIGNATURE: _________________________ DATE: ________________________
PLEASE RETURN THIS FORM:
Email:
Hand Deliver or Mail:
RJHVolunteerIntake@VIHA.CA
Attention: Volunteer Resources and Engagement
Royal Jubilee Hospital
1952 Bay Street, Royal Block, Level 4, Room 453A
Victoria, B.C. V8R 1J8
Thank you for your prompt response.
2 | Page
VOLUNTEER RESOURCES AND ENGAGEMENT DEPARTMENT
High School Students Step Up Youth Program Applicants Ages 14 to 18 Only:
TO BE COMPLETED BY PARENT/GUARDIAN
NAME OF APPLICANT: _____________________________________
NAME OF SCHOOL: ______________________________ GRADE: _______________
I am aware that the above student would like to participate in the Step Up Youth Volunteer Program for the
Royal Jubilee Hospital in Victoria.
I understand that the Volunteer Resources Department requires my child/ward to complete a minimum
of 60 hours of volunteer service, prior to asking for a reference.
If my child/ward is signing up for the Step Up program, they commit to the program from
September through to April in the school year.
I will ensure all Hospital Items will be returned upon completion of the Volunteer Placement, such as:
Photo ID, uniform, and parking permit (if issued).
I give permission for Volunteer Resources to provide references or certificates relating to my
child’s/ward’s volunteer experience to schools, education institutes, and employers who recognize and
value volunteerism.
I give permission for the Island Health to take photographs and to store registration or personal
information electronically of my child/ward. I understand that:
Information collected at the time of registration will be stored electronically and used for
management functions by the Volunteer Resources.
All Island Health volunteers are required to have official Island Health Photo Identification.
I give permission for pictures to be taken of my child/ward from time to time for publicity and display
purposes: (Please check the following boxes)
Displays
Videos
Volunteer Resources website
Island Health publications*
Brochures
Newspaper
I have read this application package.
I give my approval and support for the above my child/ward’s participation. I will support them in
attending regularly and encourage them to perform their volunteer services according to the guidelines
provides during their orientation
*Island Health publications includes Island Health’s social media accounts.
PRINTED NAME OF PARENT/GUARDIAN: ________________________________________
SIGNATURE OF PARENT/GUARDIAN: _______________________________________
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