ࡱ> tvs KbjbjcTcT vR>>  +++++????ld?2.Jx4 `1111111$5e8J1i+#*.##1++[_2k%k%k%#++1k%#1k%k%/h1+O?$ H01u202X08$8 18+1 !^k%v!L!= 11$ 2####8 :  HYPERLINK "http://www.torontomeds.com/imagine/" \o "Home page"  INCLUDEPICTURE "http://www.torontomeds.com/imagine/img/v2logo-345x103.gif" \* MERGEFORMATINET  VOLUNTEER APPLICATION FORM Clinic Volunteer PART A: Eligibility and Expectations The following UofT students are eligible to apply for this volunteer position: Current 1st year Medical Students, Current 1st year Nursing Students Current 2nd and 3rd year Pharmacy Students As an IMAGINE Clinic Volunteer: The time commitment will be 4 hours/week (Saturday), for 4 consecutive weeks Clinic Volunteer Responsibilities will include: Attend ONE (1) IMAGINE General Training Session (dates TBD) prior to the start of your volunteer responsibilities Attend ONE (1) IMAGINE Clinic Training Session (date TBD) prior to the start of your volunteer responsibilities Participate in 4 CONSECUTIVE Saturday Clinic experiences, each running from 11am-3pm. Work alongside an interprofessional team of FOUR (4) students to plan and deliver care to clients, under the supervision of a preceptor (licensed healthcare practitioner). Participate in End-of-Clinic interprofessional rounds, under the guidance of preceptors Facilitate client evaluations of clinic experiences and provide personal evaluation of clinic experiences PART B: Information Date of Application (DD-MM-YY):  FORMTEXT        First Name:  FORMTEXT      Last Name:  FORMTEXT       Sex:  FORMCHECKBOX Male  FORMCHECKBOX  FemaleProfession-Specific Information Program:  FORMDROPDOWN Year of Program:  FORMDROPDOWN Contact Information Phone no. (Home):  FORMTEXT      Email:  FORMTEXT       Phone no. (Cell):  FORMTEXT       Address:  FORMTEXT      City:  FORMTEXT       Province:  FORMTEXT      Postal Code:  FORMTEXT      In Case of Emergency (Emergency Contact) Name:  FORMTEXT       Relationship to Applicant:  FORMTEXT       Phone Number (Home):  FORMTEXT      (Work):  FORMTEXT       PART C: Questions Why do you want to volunteer with the IMAGINE Clinic? How will this help you in your future career as a health care professional? (250 word max)  FORMTEXT       What skills and experience will enable you to fulfill the responsibilities of your volunteer position? (250 word max)  FORMTEXT       How did you first hear about IMAGINE?  FORMDROPDOWN  If Other, please specify:  FORMTEXT       PART D: Volunteer Agreement & Signature All of the information contained in this application is true and the misrepresentation of any part of this application will be just and sufficient cause for termination of my volunteer placement. I understand that I am not an employee of IMAGINE and that any duties that I perform are as a volunteer. I am confident that I can successfully fulfill the expectations, as outlined in Part B of this application. I understand that it is my responsibility to update any addresses, emergency contacts or other changes to the information on this form. ABCH Q S u w 泚掁qmeUAUAUAU'hyhyCJH*OJQJaJnH tH hyCJOJQJaJnH tH hynH tH hyh5B*CJ,OJQJaJ,phh5>*CJ,OJQJaJ,h5CJOJQJaJ1hy5B*CJKH$OJQJ\aJmH phsH :jhy5B*CJKH$OJQJU\aJmH phsH (hy5CJKH$OJQJ\aJmH sH 1jhy5CJKH$OJQJU\aJmH sH H l ( X ; =     h^hgdy & Fgdygdy  & Fgdygdygdy $d@&a$$da$  & ( X J s = L r     ' ( M ξξήΟΟήΟΒw`,h55CJOJPJQJ\^JaJnH tH hyhynH tH hynH tH h5nH tH hy>*CJOJQJaJhyhyCJOJQJaJhyhy5CJOJQJaJh&hy5CJOJQJaJhyCJOJQJaJhyhyCJOJQJaJnH tH !hyCJH*OJQJaJnH tH        ' ( Ekd~%$$IfTll&& t344 laT $d$Ifgdygdyh^hgdyM N X Y   46JLNXZtvͯ͌nP@h5CJOJQJaJnH tH ;jB&h55CJOJPJQJU\^JaJnH tH ;j%h55CJOJPJQJU\^JaJnH tH h5<jh55CJOJPJQJU\^JaJmHnHtH u;j%h55CJOJPJQJU\^JaJnH tH ,h55CJOJPJQJ\^JaJnH tH 5jh55CJOJPJQJU\^JaJnH tH \^PD d$IfgdyEkd($$IfTll&& t344 laTXkd&$$IfTl0l& t344 laT d$Ifgdy  \^`|~鎂tV;j(h55CJOJPJQJU\^JaJnH tH h5CJ^JaJnH tH h5CJaJnH tH h5;j'h55CJOJPJQJU\^JaJnH tH ;j'h55CJOJPJQJU\^JaJnH tH 5jh55CJOJPJQJU\^JaJnH tH ,h55CJOJPJQJ\^JaJnH tH ^`PD d$IfgdyXkdb*$$IfTl0l& t344 laT d$IfgdyEkdP($$IfTll&& t344 laT@BVXZdfhvxƯr]rFr3Ư%h5>*CJOJPJQJaJnH tH -jh55CJOJQJUaJmHnHu(j+h55CJOJQJUaJ"jh55CJOJQJUaJh55CJOJQJaJh5CJ^JaJnH tH h5CJaJnH tH h5,h55CJOJPJQJ\^JaJnH tH 5jh55CJOJPJQJU\^JaJnH tH ;j)h55CJOJPJQJU\^JaJnH tH hPXkd+$$IfTl0l& t344 laT d$IfgdyEkd*$$IfTll&& t344 laT,Ưw`M;-h50JCJOJQJaJ#jh50JCJOJQJUaJ%h5>*CJOJPJQJaJnH tH -jh55CJOJQJUaJmHnHu(j`,h55CJOJQJUaJ"jh55CJOJQJUaJh55CJOJQJaJh5,h55CJOJPJQJ\^JaJnH tH 5jh55CJOJPJQJU\^JaJnH tH ;j+h55CJOJPJQJU\^JaJnH tH >rt=Xkd .$$IfTl0l& t344 laT d$IfgdyXkd,$$IfTl0l& t344 laT,.0:<>JL`bdnprtحؒ}fbؒMحؒ)j.h50JCJOJQJUaJh5,h55CJOJPJQJ\^JaJnH tH )j-h50JCJOJQJUaJh50JCJOJQJaJh55CJOJQJaJ%h5>*CJOJPJQJaJnH tH .jh50JCJOJQJUaJmHnHu#jh50JCJOJQJUaJ)j8-h50JCJOJQJUaJNPRhj~ةt_Iةt*jh50JCJOJUaJmHnHu)j0h50JCJOJQJUaJh50JCJOJQJaJh55CJOJQJaJh5CJ^JaJnH tH h5CJaJh5,h55CJOJPJQJ\^JaJnH tH .jh50JCJOJQJUaJmHnHu#jh50JCJOJQJUaJ)j.h50JCJOJQJUaJPRVD d$IfgdyEkd/$$IfTll&& t344 laT d$IfgdyXkdl/$$IfTl0l& t344 laTXcQ= ad$@&Ifgdy ad$IfgdyEkdX1$$IfTll&& t344 laT d$IfgdyEkd0$$IfTll&& t344 laT02FHJTVhj~ث،w_ؚ،J_ؚB>h&h5OJQJ)j2h50JCJOJQJUaJ.jh50JCJOJQJUaJmHnHu)j1h50JCJOJQJUaJh50JCJOJQJaJh55CJOJQJaJh5,h55CJOJPJQJ\^JaJnH tH *jh50JCJOJUaJmHnHu#jh50JCJOJQJUaJ)j0h50JCJOJQJUaJpjpd^$If$If`0.~&&#$$d%d&d'd+D/NOPQXkd2$$IfTl0l& t344 laT " dhjܢܖvdvOd(jS5h55CJOJQJUaJ"jh55CJOJQJUaJh55CJOJQJaJj3h5Ujh5Uh50JCJPJaJ%jl3h5CJOJQJUaJ&jh5CJOJUaJmHnHu%j2h5CJOJQJUaJh5CJOJQJaJjh5CJOJQJUaJhQh5-+gkd5$$Ifl$h% t0644 la$Ifekd4$$Ifl$h% t0644 laLHHHHHHHIIIIIIIPIÿê|i|_|L|_$j6h5OJQJU\^Jh5OJQJ^J$jD6h5OJQJU\^Jjh5OJQJU\^Jh5OJQJ\^JU h55CJOJQJ\^JaJh5CJOJQJ^JaJ hyhyhyh5h55>*CJOJQJaJ"jh55CJOJQJUaJ-jh55CJOJQJUaJmHnHuLNklDEIIPIQIII!J{JJJ d@&gdHad7$8$H$gdHa $d@&a$d@& d7$8$H$gdyI consent to have a picture/videotape/interview of me for the purpose of obtaining material which may be used in a brochure, internet web page, news story, feature or broadcast for promotional material for the IMAGINE Clinic.  FORMCHECKBOX  Yes  FORMCHECKBOX  No If accepted as a volunteer I agree to follow the above. Name of Applicant: ____________________________________________ Date ___________________________ DD-MM-YY PLEASE BE ADVISED THAT YOU WILL BE REQUIRED TO SIGN THIS APPLICATION AT A LATER DATE Signature of Applicant: ____N/A for Now____________________ Date _____N/A for now________ DD-MM-YY THANK YOU for applying to volunteer with IMAGINE. 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