Culture Connections Application Form

Contact details

Full name: *

Address: *

City: *

Postal code: *

Home phone:

Cell phone:

Email address:

Motivations and experience

How did you hear about Culture Connections?: *

Why would you like to volunteer as a host?: *

Relevant education, employment or volunteer experience:

What can you offer a newcomer?: *

Have you ever worked or volunteered with MOSAIC before? If so, please tell us when, where, and in what capacity: *

Tell us about yourself

The information you provide in this section will help us match you with an appropriate newcomer.

Gender: *

Age: *

Country of origin: *

Length of time in Canada: *

First language: *

Other languages:

Occupation: *

Please describe yourself as a person:

Please describe your hobbies and interests: *

Please describe your home life (you can select more than one): *

Single

Married/Common Law

Children

No Children

Are you a smoker?: *

Mode of transit (you can select more than one): *

Car

Public transit

Bicycle

References

Please provide two references. Applicants who cannot provide this information may be excluded from volunteering as a host. We will contact your references and may also contact other people to determine your suitability for the volunteer position.

Professional reference

Full name: *

Relationship to you: *

Length of relationship: *

Phone number: *

Email address: *

Personal reference

Full name: *

Relationship to you: *

Length of relationship: *

Phone number: *

Email address: *

Emergency contact

Full name:

Relationship to you:

Phone number:

Police record check

You will be required to undergo a police record check if your partner has children or belongs to a vulnerable population group. MOSAIC will reimburse you if there is a cost involved.

Are you willing to undergo a police record check if required and provide this information to MOSAIC?: *

Yes

Applicant agreement

I agree that all information provided in this application is accurate and has been given voluntarily.

I understand that MOSAIC will keep my personal information private but may share part of it with the references I have provided, potential newcomers and government employees who evaluate the Culture Connections program.

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