Volunteer Pilot Application - Cornwall Seniors on Wheels Program

Thank you for volunteering as an e-passenger bike pilot for the Seniors on Wheels program this summer!

Name:

Address:

City, province

Postal code:

Email address:

Home phone:

Cell phone:

Emergency contact name:

Emergency contact phone number:

I have a valid driver's license.

Yes

No

I have had a COVID-19 vaccination.

Yes

No

I have a vulnerable sector police check from the past year.

Yes

No

I currently volunteer with...

I am currently employed by...

I have First Aid or CPR training...

Yes

No

I have a medical condition that may affect my ability to participate (like heart conditions, vision difficulties, etc.)?

Yes

No

Why do you want to be a pilot with the Seniors on Wheels program?

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