ORN Form - YMCA Northumberland

Have you volunteered for Operation Red Nose in the past? (click all that apply)*
- 2016
- 2017
- 2018
- 2019
- 2021
- No, this is my first year volunteering
Offence Declaration I DECLARE since the last Criminal Records Check provided to YMCA Northumberland, or since the last Offence Declaration Form submitted YMCA Northumberland, that: I have no convictions under the Criminal Code of Canada up to and including the date of this declaration for which a pardon has not been issued or granted under the Criminal Records Act (Canada). I have no pardons related to sexually based offenses up to and including the date of this declaration under the Criminal Records Act (Canada). I have no charges pending under the Criminal Code of Canada up to and including the date of this declaration. I have not been the subject of any criminal investigation or allegation, any child welfare investigation or allegation, nor have I had any charges brought against me, even if the charges are pending. My driver’s license has not been suspended or restricted for any reason.
Please select the appropriate line:
- There have been no occurrences as described above since my last Criminal Record Check or Offence Declaration Form.
- All reportable matters as described above were discussed with Agency Staff and/or the Executive Director at the time of the occurrence(s).
Offence Declaration Agreement*

By typing my name above, I hereby attest that the information disclosed herein is true, complete and accurate to the best of my knowledge and belief. I understand that failure to complete an accurate and truthful Offence Declaration will lead to a review of my continued service with YMCA Northumberland.
Police Check

I hereby volunteer my services for this year’s campaign. I authorize any police service with jurisdiction over any or all parts of Ontario to conduct a background check for any arrests, charges or convictions for a criminal offence for which I have not received rehabilitation or a pardon, and for any penal offence. I also authorize all police services to verify the validity of my driver’s license. I authorize all police services to forward the results of the background check to the Communications and Marketing Coordinator. In accordance with the relevant legislation, I agree to protect the confidentiality of all information and data disclosed to me about Clients and Volunteers. I certify that the information provided is accurate and complete. Furthermore, between the time I submit this form and the time I participate as a volunteer, I will inform Operation Red Nose of any changes that would result in my no longer meeting the selection criteria.
Please send a photocopy of your drivers licence to Kim Lauder, Coordinator, Communications and Marketing at [email protected], and she will arrange for your new/updated police check.
I agree to:

Take all necessary precautions to ensure the safety of my team and of Operation Red Nose clients by complying with, among others, the highway Safety Code (speed limits,seatbelts, parking, etc). Operation Red Nose is not responsible for any tickets received during the course of my volunteer duties.
Comply with the Operation Red Nose code of ethics.
Sobriety: I must not consume any alcohol or cannabis on the day I work with Operation Red Nose.
Confidentiality: All information about Operation Red Nose clients and volunteers that is disclosed to me will remain confidential and will not be used for any purpose other than fulfill the mandate conferred upon me. I will also not disclose any details with other volunteers that could be used to identify a client or volunteer.
Courtesy: I will show patience and courtesy toward clients at all times.
Free Service: Operation Red Nose is a free service. I will not solicit donations, but if clients wish to make a donation I will take them.
Fatigue: Operation Red Nose volunteers must often deal with fatigue, and its effects at night must not be underestimated. Therefore, I will not overestimate my capabilities and if necessary take a nap before reporting for duty as an Operation Red Nose volunteer.
Mutual Respect: All Operation Red Nose volunteers deserve my full respect and consideration.
Return to Operation Red Nose all donations, tips and gifts given to me while I volunteer.
If I do not honour my commitment, Operation Red Nose reserves the right to terminate my participation as a volunteer for the current and future campaigns. The decision of Operation Red Nose is final.
Agreement and electronic signature*

please type your name in the signature box, to agree to application terms.

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Operation Red Nose Northumberland - Volunteer Application

Step 1 of 4 - Volunteer Availability

Drivers License information. *Mandatory for drivers and escorts

Police Check

I agree to:

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