Member/Volunteer Application

Chapter / Community Leader

Which Chapter/CL are you applying to become a volunteer/member with? *

Your Contact Information

Name *

Address *

Country

City

State

Zip code

Phone *

Email *

Information About You

I am applying to become a... *

Member only

Volunteer only

Member and Volunteer

Do you wish to receive MADD Canada's updates from the National Office?

Yes

No

I am a... *

Concerned Citizen

Victim or Survivor of Impaired Driving

College/University Student

Have you ever been charged or convicted of a Criminal Code impaired driving offence, or criminal offence or charged under the Highway Traffic Act of the Motor Vehicle Act? *

Yes

No

If yes, please explain:

Do you have any previous experience as a volunteer? If so, with what organizations, and what kind of work did you do?

Why, at this particular time in your life, have you chosen to volunteer with us?

Are you willing to make a one year commitment?

Yes

No

Do you have access to a vehicle?

Yes

No

Some volunteer positions require a police records check at our cost. Are you willing to have a police records check completed if it is required? *

Yes

No

When are you available? (Please check all that apply)

Days

Evenings

Weekends

Flexible

Personal References

(Examples: employer, charitable organization, teacher, neighbour)

Reference 1: Name *

Reference 1: Phone number *

Reference 2: Name *

Reference 2: Phone Number *

Statement of Beliefs and Code of Conduct

I have reviewed and agreed to abide by the Statement of Beliefs and MADD Canada’s Volunteer Code of Conduct. *

See links at the beginning of this form.

Yes

Date *

Submit Your Application

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Member/Volunteer Application