Emergency Management Volunteer Application First Name *Last Name *Email Address *Phone Number *Occupation Work Location Home AddressPostal Code Message0 / 180BC Driver’s LicenseYesNoDo you have reliable personal transportation? YesNoEnglish Comprehension ReadWrite SpeakIndicate which team(s) you are interested in joiningSupport Services ( ESS )General Services UnitEmergency Management TeamBriefly explain why you wish to volunteer with the District of Lillooet Emergency Management program:0 / 180Emergency InformationEmergency Contact NameRelationshipContact's Phone #Contact's Email AddressList any relevant certifications, qualifications, skills or experience that you think may be of benefit to your role 0 / 180List any service limitations (i.e. heavy lifting, etc) 0 / 180ReferencesRefrence's NameRefrence's Phone #Refrence's NameRefrence's Phone #Refrence's NameRefrence's Phone #CONFIDENTIALITYBy checking boxes and signing this form, you are agreeing to the terms and conditions defined belowI acknowledge and confirm that as a volunteer, I may acquire confidential information which may contain personal information, and that such information will remain in the strictest confidence, that individuals’ personal information is protected from unauthorized disclosure by the Freedom of Information and Protection of Privacy Act, and that unauthorized disclosure of individuals’ personal information is an offence under that Act. The unauthorized disclosure of such information to any unauthorized person, including making copies of any documents or records which contain or are derived from such information, is forbidden and is grounds for immediate dismissal and potential prosecution. I agree to not discuss the details of my volunteer work, present or past with any representative of the media or any unauthorized person, or publicize any of the confidential aspects of my position by any medium of communication unless specifically given instruction to do so by my direct supervisor and/or a District Of Lillooet staff person. I agree to direct all enquiries from the media to the designated Distirct of Lillooet staff member or authorized agency. DISMISSAL & TERMINATING THE VOLUNTEER RELATIONSHIPI understand that I am viewed by the public as an agent of Distirct of Lillooet, Emergency Management BC (EMBC) and that if I act in a manner that is considered unsatisfactory or unbecoming, that this will be addressed by the Distirct of Lillooet through the following disciplinary process up to an including dismissal. I agree that I will provide written notice to the Distirct of Lillooet when I wish to terminate my volunteer relationship. On terminating my volunteer relationship with the Distirct of Lillooet, I will return any issued equipment, keys, uniform and my EMBC identification card within 2 weeks of termination or as agreed upon with Distirct of Lillooet staff. FREEDOM OF INFORAMTION AND PROTECTION OF PRIVACY ACT NOTICEBy checking boxes and signing this form, you are agreeing to the terms and conditions defined belowPersonal information collected on the Distirct of Lillooet Volunteer Application Form is collected under the Freedom of Information and Protection of Privacy Act section 26(c) and will be used for the purpose of the Distirct of Lillooet volunteer program. If you have any questions about the collection and use of this information please contact the Distirct of Lillooet Emergency Management at (250) 256-4289.DISCLAIMERBy checking boxes and signing this form, you are agreeing to the terms and conditions defined belowI certify that all answers given by me on this volunteer application form are true, correct and complete to the best of my knowledge. The Distirct of Lillooet has my consent to contact the references I have identified in this application. I have contacted the above references to confirm their contact information and their willingness to provide a reference for me. I have read the “Responsibilities of a Volunteer” statements and understand that breaching of any of these responsibilities would be cause for termination of my volunteer position. I agree to comply with Distirct of Lillooet policies, rules and regulations. I acknowledge that the Distirct of Lillooet is under no obligation to accept me as a volunteer. Digital SignatureBy adding your digital signature you are in effect signing this form, and you are agreeing to the terms and conditions defined as have been defined0 / 180
