MHAC 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.

 

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

*
Phone (Home):

*
Phone (Work):

Phone (Other):

Email (Required):

1. Why are you interested in participating on the Mental Health Advisory Council?

2. Please describe any experiences you have had directly or in a support role with mental health services or those living with mental illness.

3. Why is mental health important to you? 

4. Are there particular issues or areas that you would like this Council to focus on?

5. Have you participated on other boards, committees, councils, etc.?

6. What skills, experience, and/or insight do you feel you would bring to the council?

Are you 18 years old or over?

Yes
No

How did you hear about the Mental Health Advisory Council?

Free Press
Community newspaper
Community organization
Health organization
TV or radio advertisement
Member of a Community Health Advisory Council

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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