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Home » Forms » LHIG Application Form

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.

"*" indicates required fields

Name*
Address*

Note: We are looking for community members - from high school students to older adults - who have a broad interest in health and the factors that impact on the health of communities. This question is being asked to help ensure a wide range of ages are represented on the Local Health Involvement Group.

If you are under the age of 18, parent / guardian consent is required to volunteer. Upon submission of your application, a Parent / Guardian Consent Form will be sent to you for your parent / guardian to complete.

Are you currently (Please check one):
How did you hear about the Local Health Involvement Groups?

References

Please provide two (2) references. We will not contact your references until after you have been interviewed. Please note references from family members or from personal friends will not be accepted, unless you were employed by them.

Reference #1

Name

Reference #2

Name
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.
This field is for validation purposes and should be left unchanged.

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