COVID Volunteer Application Form

Immediate Need for Volunteers to Support COVID-19 Vaccinations

Required field - must be filled in. A red asterisk (*) indicates required fields.

At this time a special COVID-19 Volunteer pool is being created to provide support to Immunization Clinics across the province.

If you are interested in volunteering to assist in immunization, and have previously worked in one of the following classifications, please complete the electronic screening questions below and you will contacted by a member of the Volunteer Services Recruitment Team:

Advanced Care Paramedic
Critical Care Paramedic
Licensed Practical Nurse
Nurse Practitioner
Pharmacist
Physician
Registered Nurse

*Please select the zone where you are interested in volunteering:

Central Zone (Halifax Regional Municipality, Eastern Shore, Windsor, West Hants)
Northern Zone (Colchester East Hants, Cumberland and Pictou)
Western Zone (Annapolis Valley, South Shore, South West Nova Scotia)
Eastern Zone (Cape Breton, Guysborough, Antigonish, Strait Richmond)

Personal Information

*First Name:

Middle Name (if applicable):

*Last Name:

*Phone Number:

Email Address:

*Address

*City

*Province

Postal Code

Additional Information

*Are you interested in Vaccination Clinic volunteer opportunities?

YesNo

*Are you a current or former employee of Nova Scotia Health (NSH) or one of the former district health authorities/employers?

I've never been employed by NSH or one of the former district health authorities
I am a former employee
I am a former retired employee
I am a current employee of NSH
I am a current employee of NSH -AND- IWK
I am a current employee of IWK

*What is your highest level of education?

Less than Grade 12 or GED
Grade 12 or GED
Some college/university
Completed Diploma Program/Bachelor's Degree
Completed Master's Degree
Completed PhD

*Did you previously work in one or more of the following occupations?

Advanced Care ParamedicPharmacist
Critical Care ParamedicPhysician
Licensed Practical NurseRegistered Nurse
Nurse PractitionerOther

If other, please specify:

*Do you currently hold an active–practicing license/registration/certification with the appropriate licensing/regulatory body?

Yes
No
I hold temporary/conditional license/registration/certification
I am eligible for license/registration/certification

*Do you currently hold active certification in CPR/First Aid?

Yes
No

Please list the date of your last CPR certification (if applicable)

*Have you completed an approved immunization and injection training program?

Yes
No

*Do you currently hold a permit to administer drugs by injection from the Nova Scotia College of Pharmacists?

Yes
No

*What is your earliest availability to volunteer?

Immediately
In the next 1-2 weeks
In the next 2-4 weeks
Beyond 4 weeks

Volunteer opportunities are available for a minimum of four hour blocks from 7:30am to 7:00pm. What days of the week and for how many hours on each day are you available? For example, Sundays – not available, Mondays – 4 hours starting at 3:00pm, Tuesdays – 5 hours starting at 7:30am.

Sunday:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

* I hereby certify that the facts set forth in this application are true and complete.

*Please enter the text below.

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COVID Volunteer Application Form

Immediate Need for Volunteers to Support COVID-19 Vaccinations

Personal Information

Additional Information

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