Public & Patient Engagement

Local Health Involvement Groups Application Form

All information on this form whether submitted online or in paper directly to the Winnipeg Regional Health Authority (WRHA) will be entered to a website owned by Volgistics, Inc. and not the WRHA. 

Volgistics is a third party contracted to manage and store all information on volunteers collected by the WRHA, including, but not limited to: this application, personal information, volunteer assignments, service hours, awards, etc.  Volgistics currently stores this information on servers located outside of Canada.  This information will be subject to the laws of the country where it is kept.

The WRHA are not responsible for any lost or misdirected data or for any delays while data is being sent to or stored on the Volgistics website.  Information about Volgistics’ Security Features, Privacy Policies and Terms of Use can be found on its website at www.volgistics.com.

Please note: Fields marked with a * are required fields

Mr. Ms. Mrs.
Name: *
Address (Please include Postal Code):

*
Phone (Home):

*
Phone (Work):

Phone (Other):

Email Address:

*

Which area do you live in?


What neighbourhood do you live in?

How many years have you lived there?

1. Why are you interested in participating on a Local Health Involvement Group?

2. Are you involved with any groups or initiatives in your community? How would you describe your community?

3. What insights, experience, and perspectives do you feel that you would bring?

Are you currently (Please check one):

Retired
A student
Working in your home
Employed
Unemployed

If employed, what is your occupation?

As we would like the opportunity to reflect the diversity of each community in membership on the Groups, you are invited to indicate if you are from any of the following groups: women, aboriginal people, visible minorities, and persons with disabilities:

How did you hear about the Local Health Involvement Groups?

Free Press
Community newspaper
Community organization
Health organization
TV or radio advertisement
Member of a Local Health Involvement Group

Other:

Please provide the names of two people who could be contacted as references:


#1 Name/Address/Phone:



#2 Name/Address/Phone:


Disclaimer

I hereby authorize the WRHA to contact the named references to ascertain my suitability as a volunteer.  I hereby release the WRHA from all liability for any damages whatsoever for obtaining and using same. 

By submitting this application, I agree that the information I have provided on the form is true and accurate. Furthermore, I understand and agree that submitting this application form does not automatically register me as a volunteer. It is the policy of WRHA Volunteer Services to screen all prospective volunteers. While we try to place every prospective volunteer, management reserves the right to decline applicants who do not meet our requirements and/or placement criteria. I consent to this information and information about my volunteer work with WRHA to be maintained on the Volgistics website and absolve and release the WRHA from all and any liability that may otherwise accrue by reason of keeping this information on the Volgistics website and using this information for WRHA purposes.

with the above disclaimer

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Traditional Territories Acknowledgement
The Winnipeg Regional Health Authority acknowledges that it provides health services in facilities located on the original lands of Treaty 1 and on the homelands of the Metis Nation. WRHA respects that the First Nation treaties were made on these territories and acknowledge the harms and mistakes of the past, and we dedicate ourselves to collaborate in partnership with First Nation, Metis and Inuit people in the spirit of reconciliation.
Click here to read more about the WRHA's efforts towards reconciliation

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