Application Form - Alzheimer Society of Durham Region

Volunteer Agreement:

*If you are under the age of 18, this form must be completed by a parent or legal guardian.

In consideration for being permitted to participate as a volunteer for the Alzheimer Society of Durham Region (ASDR), I understand and agree to the following:

• I will not receive any remuneration, salary, wage, payment or any employee benefit whatsoever, or be covered by Workers’ Safety and Insurance benefits.
• Except as authorized by Alzheimer Society Durham staff, I will not use the ASDR facilities and equipment.
• I agree to assume all risk of loss or injury (including death) to myself or damage to my property while on any of the premises of ASDR and elsewhere resulting directly or indirectly from my activities and performance as a volunteer. In the event that I am injured and my next of kin cannot be contacted, I give my permission to the attending physician to render such treatment as would be normal.
• I release the Alzheimer Society of Durham Region and its affiliates, elected officials, directors, officers, employees, agents and assigns for any and all claims for personal injury (including death) and/or property damage that may arise from, or be in any way connected to, my participation as a volunteer for the Alzheimer Society of Durham Region. I understand that this release applies to both present and future injuries and that it binds my heirs, executors and administrators. I have read this release, understand its terms and agree to it voluntarily and with full knowledge of its significance.
• I understand that in the course of participating in the volunteer program, I may be in receipt of Alzheimer Society of Durham Region confidential information including, but not limited to, client identities, materials, records, memoranda, data and results pertaining to, arising from or containing particulars of confidential information. I agree that I shall not at any time while I am providing volunteer services for the Alzheimer Society of Durham Region or at any time after those services are completed, disclose to anyone such confidential information, except as may be required or permitted by law, or at the request of the Alzheimer Society of Durham Region, or as required to perform the volunteer services.
• I agree that all material prepared by me, in the performance of my volunteer services, including copyright therein, shall become the sole property of the Alzheimer Society of Durham Region. I assign and transfer to the Alzheimer Society of Durham Region all my rights, title and interest (including intellectual property rights) in all such material, and I waive any moral rights I may have with respect to such material in favour of the Alzheimer Society of Durham Region and any of its assignees and licensees.

Conditions of Volunteering:

Prior to commencing my volunteer services at the Alzheimer Society of Durham Region, I understand and agree to the following:

• I may be asked to provide a Police Vulnerable Sector Check (PVSC).  The Alzheimer Society of Durham Region will require a PVSC for any volunteer position where the volunteer will be in a position of trust or authority with Vulnerable Persons. “Vulnerable Person(s)” means any person(s) who, because of their age, a disability, or other circumstance, whether temporary or permanent, are in a position of dependence on others, or are at a greater risk than the general population of being harmed by a person(s) in a position of authority or trust towards them.  Examples include children, the elderly or persons with disabilities.
• I may be asked to provide 3 letters of reference.
• I will attend all necessary orientation, training and screening specific to my volunteer position at the Alzheimer Society of Durham Region.
• I will be trained on the operating policies and procedures of the Alzheimer Society of Durham Region and the Accessibility for Ontarians with Disabilities Act.
• I will attend a Volunteer Orientation Workshop.
• In order to volunteer for Alzheimer Society of Durham Region, I must be at least 14 years of age. In a worksite that could be considered a "factory" under the Occupational Health & Safety Act, I must be at least 16 years of age.
• I confirm that the information I provide to the Alzheimer Society of Durham Region will be true and complete to my knowledge.
• I understand that a false statement may disqualify me from volunteering or be a cause for immediate termination from a volunteer position.
• I authorize the Alzheimer Society of Durham Region to collect and use my personal information to determine eligibility and suitability for volunteer placement with the Alzheimer Society of Durham Region.
• I understand that the information obtained will be confidential, but may be shared with organizations relevant to the position applied for.

Story, Photograph, Video and Voice Recording Consent, Waiver, Indemnity and Release Form:

At the Alzheimer Society, we strive to educate Canadians about Alzheimer’s disease and other dementias by sharing photos and sometimes stories of people with dementia, their caregivers and families.

By giving the Alzheimer Society of Durham Region permission to use your story and photo on the website (www.alzheimer.ca/durham) and sub-sites, on official Alzheimer Society social media platforms, in publications or advertising/promotional materials you are helping us to build awareness that will bring us one step closer to our vision: To live in a community where people with Alzheimer's disease and related dementias are accepted and supported in their environment.

These photos will be added to the Alzheimer Society of Durham Region image bank and will remain accessible for the Society’s use. If you would no longer wish to have your picture used where applicable we can have it removed; you may contact the Alzheimer Society of Durham Region in writing at information@alzheimerdurham.com Alzheimer Society of Durham Region will make every effort to inform you each time your story or photo is being used.

•  I grant to the Alzheimer Society and its representatives the right to reproduce, use, exhibit, display, broadcast and distribute and create derivative works of these images and recordings in any media now known or later developed as well  as my name for promoting, publicizing or explaining the Alzheimer Society and its activities and for administrative, educational or research purposes. I acknowledge that the Alzheimer Society owns all rights to the images and recordings.
•  I consent to my name, photo, and (if applicable) my story being included in media or promotional materials for the Alzheimer Society. I realize that this material may also be used by other Alzheimer Societies across Canada.

Collection of Personal Information

It is the Society’s practice to protect the privacy and confidentiality of stakeholder confidential information.

This privacy policy applies to all agents of the Society, including employees, volunteers, students, vendors, contractors, consultants, researchers, and health care practitioners, who, on behalf of the Society, collect, use, disclose or have access to confidential information in carrying out their assigned duties.

Confidential information includes information about all stakeholders, including clients receiving services, employees, volunteers, and donors.

Personal information is any information that can be used to distinguish, identify or contact a specific individual. This information can include an individual’s opinions or beliefs, as well as facts about or related to, the individual.

For further information about our confidential information protection practices, or to raise a concern you have with these practices, please contact the Executive Director.

The information collected on the Volunteer Application is used to determine eligibility for a volunteer placement. Questions about this collection can be directed to the Alzheimer Society of Durham Region, 1600 Champlain Ave., Suite 202 Whiby, ON L1N 9B2: 1. 888. 301. 1106 or 905. 576. 2567 EXT 5235 volunteer@alzheimerdurham.com

Conflict of Interest

No person who has a conflict of interest with any activity or program of the Society whether personal, philosophical or financial shall be accepted or serve as a volunteer with the Alzheimer Society.  If you think that you may have a conflict of interest, speak to the Coordinator of Volunteers immediately.

Non-Receipt of Goods and Services

While volunteering with the Alzheimer Society of Durham Region, volunteers are not allowed to receive gifts of any monetary value from the person with dementia their family, or their care partners. This rule is in place in order to protect the vulnerability of persons with dementia, their family, and their care partners. It also serves to protect the integrity of the Alzheimer Society of Durham Region Volunteer Program. If a volunteer is receiving any gifts of value, it will be considered as a conflict of interest and will compromise their placement in the Volunteer Program.

I, hereby declare that I will not receive gifts of value, money, property, or services of any kind from the person with Dementia, their family, or their care partners