Leisure Buddies Program - Volunteer "Buddy" Registration Form

NOTICE OF COLLECTION OF PERSONAL INFORMATION

The personal information collected on this form is collected under the authority of the Municipal Act 2001 as amended, and will be used to administer the Age Friendly Leisure Buddy program. Questions about this collection should be addressed to Michelle Dellamora at 355 Wellington St., Suite 248, London, Ontario, N6A 3N7. Tel: (519)661-CITY (2489) ext. 7208.

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* 1. Personal Information

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* 2. Preferred Method of Contact:

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* 3. Emergency Contact Information

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* 5. Are you able to commit to the Leisure Buddy Program for one year?

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* 6. What Modes of Transportation are Available to You? Check all that apply.

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* 7. Which of the following areas of the City of London you are able to access? Check all that apply.

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* 8. Relevant Volunteer or Work Experience # 1

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* 9. Relevant Volunteer or Work Experience # 2

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* 10. Other Skills or Experience:

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* 11. Do you speak any languages other than English? If yes, please list below.

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