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Received: ___________________________
Interviewed: _________________________
Trained: ____________________________
Volunteer Application
Name:
Surname
First
Middle
Please list all previous surnames/maiden names: ____________________________________________
______________________________________________________________________________________
Address:
Number
Street
Apt.
City
Province
Postal Code
Birth Date: ________________________________
Phone # (home):
(business):
Email: _____________________________________
Cell Phone or Pager: _______________________
Do you have access to a vehicle?
Do you have adequate insurance?
Do you speak a second language?  Yes  No
If yes, please indicate here: _________________
Would you be willing to use your second language?  Yes  No
Emergency Contact:
Phone:
Relationship:
Highest Level of Education Completed (please check):
 Grade School
 High School
 College
 University
Area of concentration:
Current place of employment: ___________________________________ Hours per week: ________
Length of employment: ____________ Position or duties: ____________________________________
Tel: (519) 436-6630 ~ E-mail: crystalal@chatham-kent.ca
Other training which may be relevant (CPR, workshops, certificates etc.):
Interests, skills and hobbies:
Present / Previous Volunteer Experience:
Are you able to work with confidential information?
Yes _____
No _____
Have you ever been charged with a criminal offense in which a pardon has not been granted?
Yes _____No _____ if yes, please explain:
Would you object to a police check?
Yes _____
No _____
How did you hear about the program?
Briefly state why you are interested in becoming a volunteer with Victim Services:
Shift Availability (please check all that apply): All shifts are 12 hours on-call (Day shift 7am to 7pm &
Night shift 7pm to 7am) 4 shifts (requirement) per month are chosen by volunteers monthly on a first come
first serve basis. *On call means you are ready to go out to a crisis call should you be dispatched by your
team lead.
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
DAY SHIFT:
7AM -7PM
NIGHT SHIFT:
7PM -7AM
How long of a commitment could you realistically make to this service?
______________________________________________________________________________________
Tel: (519) 436-6630 ~ E-mail: crystalal@chatham-kent.ca
Is there any other information that you feel staff should be aware of?
Please list three references: At least one work related, one personal, and one of your choice, no family
members will be accepted as references:
1.
Name:
Phone:
Address:
Email Address:
Occupation:
2.
Relationship:
Years Acquainted:
Name:
Phone:
Address:
Email Address:
Occupation:
3.
Relationship:
Years Acquainted:
Name:
Phone:
Address:
Email Address:
Occupation:
Relationship:
Years Acquainted:
In making this application, I give permission to Chatham-Kent Victim Services
to contact the persons named as references to ascertain my suitability as a volunteer. Also, I realize that
a recent police clearance will be required to determine eligibility. Furthermore, I give Chatham-Kent
Victim Services permission to circulate my name to members of the Chatham-Kent Police Service for
internal screening purposes.
Applicant’s Signature:
Date:
Please return this application form to:
Chatham-Kent Victim Services
24 Third Street, Box 366,
Chatham, ON N7M 5K5 Or fax to: (519) 380-6028
Tel: (519) 436-6630 ~ E-mail: crystalal@chatham-kent.ca
Chatham-Kent Victim Services
24 THIRD STREET, P.O. BOX 366
CHATHAM, ON N7M 5K5
Office: 519-436-6630 Fax: 519-380-6028
Dear Interested Volunteer,
Chatham-Kent Victim Services is a non-profit organization, which provides
assistance for those who have been victims of crime, trauma or tragic circumstance in
Chatham-Kent.
Volunteers are trained in communication, crisis intervention, traumatic stress,
and victim’s issues to ensure that our community’s needs are met 24 hours a day, seven
days a week. Volunteers respond on an on-call basis, and their presence throughout
Chatham-Kent ensures that needs are met for both rural and urban areas.
Our referrals may include such incidents as assault, break and enter family
occurrence, fire, homicide, property crimes/damage, robbery, sexual assault, spousal
abuse, stalking, sudden death, suicides, and traffic accidents. In addition to fear, rage,
isolation and confusion, many victims experience intense mental and physical distress.
At one time or another in our lives, we all face a crisis situation. Immediate emotional
support and practical assistance can help victims cope effectively with crisis.
OUR OBJECTIVES ARE TO:
LESSEN the trauma of being victimized.
HELP victims cope with the impact of crime and/or traumatic experiences.
ASSIST victims in accessing appropriate support services in our community.
PROVIDE an opportunity for community members to become more involved in
dealing with the effects of crime and trauma.
EDUCATE community members and promote victim services in ChathamKent.
Tel: (519) 436-6630 ~ E-mail: crystalal@chatham-kent.ca
Crisis Response Volunteers
Volunteers provide support and referrals to victims in our community. We ask for a
commitment of four to six 12-hour shifts per month on an on-call basis. Shifts
available include daytime (7am-7pm) and evening/overnight (7pm-7am). Volunteers
work in teams of two and support is provided on-scene or over the telephone, as the
circumstance dictates.
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Must be 21 years or older.
Must reside in Chatham-Kent area.
Must have access to a vehicle, valid driver’s license and insurance.
Must consent to a security clearance investigation and personal reference checks
Must become familiar with the procedures of the Chatham-Kent Victim Services and
successfully complete the required in-depth and on-going training.
Must be willing to sign an oath of confidentiality which requires a volunteer not to
disclose or give to any unauthorized person any information or document that has
come into their knowledge or possession while working as a volunteer.
Must be prepared to volunteer a minimum of 4 (12-hour) shifts per month and to
attend regularly scheduled meetings.
VICTIM ASSISTANCE VOLUNTEER POSITION SUMMARY
Direct Service Responsibilities:
 Respond immediately to requests for victim assistance from emergency personnel by
attending on site or at an alternate safe premise. (On occasion, crisis assistance may
be done by telephone). Shifts are done on an on-call pager basis.
 Provide emotional support and companionship, including answering questions and
providing information that will help lessen the impact of the crisis for the victim.
 Provide practical assistance as needed. This may include transportation and/or
accompanying the victim to emergency services (e.g. a shelter or hospital), making
phone calls upon request or alternate arrangements as required, helping to secure
premises, and other similar tasks.
 Identify long–term needs by responding to victim’s concerns, and supply the victim
with appropriate options and referrals to services in the community that will assist
the victim in accessing resources for further assistance.
 Report activity to the Chatham-Kent Victim Services Coordinator of Volunteer
Services or Team Leader upon completion of a service call.
 Complete client contact form and submit it to the office by the next working day.
 Participate in the evaluation of the service call and provide relevant information to
the Coordinator of Volunteer Services for client follow-up.
Other Duties and Responsibilities:

Participate regularly in monthly training meetings and other volunteer training
events as scheduled.
Tel: (519) 436-6630 ~ E-mail: crystalal@chatham-kent.ca
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Report back to the Coordinator of Volunteer Services when a victim assistance call
or assignment is particularly stressful. Individual attention and debriefing will be
made available to assist the volunteer.
Bring attention to the Coordinator of Volunteer Services any inappropriate
volunteer behaviour or victim complaint that could affect the effectiveness of the
program.
We provide a comprehensive 75+ hours Core Training Program and we offer additional
training specific to the needs of victims and community services during the year. As
well, we provide recognition for your services and we offer the opportunity for
volunteers to truly make a difference in our community.
Please fill out the application form and drop it off at the Chatham-Kent Police Service,
attention Victim Services, fax it to (519) 380-6028 (if problems please fax to 352-0507)
or mail it to:
Chatham-Kent Victim Services
24 Third St, Box 366
Chatham, ON N7M 5K5
Kindest regards,
Chatham Kent Victim Services
Tel: (519) 436-6630 ~ E-mail: crystalal@chatham-kent.ca