Momentum Walk In Counselling is a Registered Charity and our Charitable Registration Number is 76950 2923RR0001

Contact Information

First Name (*):

Last Name (*):

Email (*):

Primary Phone (*):

Alternate Phone:

Address (*):

City (*):

Province (*):

Postal Code (*):

Education

I am currently a student at (*):

Program of study (*):

Anticipated Practicum start date (*):

I am willing to split a practicum between two sites (*):

Experience

How did you hear about our practicum student opportunity? (*):

Have you volunteered with us before? (*):

If yes, in what capacity?:

Do you speak any languages other than English? (*)

If yes, which ones?

Are you accustomed to working with team feedback? (*):

Are you able to volunteer at Momentum once a month for one year, after the completion of your practicum? (*):

Do you have training in crisis intervention (suicide intervention, family violence, distress line etc…)? (*):

If yes, which ones?

Are you willing to do additional training if requested by Momentum? (*):

Emergency Contact

Name (*):

Relationship (*):

Primary Phone (*):

Alternate Phone:

References

Please provide the names of two employment, education or volunteer-related references (not friends or family members). Please ensure you notify your references in advance of our call.

Name (*):

Relationship (*):

Email (*):

Primary Phone (*):


Name (*):

Relationship (*):

Email (*):

Primary Phone (*):

Resume

Upload Resume that includes education, employment and volunteer history (PDF or Word Docs):

Agreement

The above information is true and accurate

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Walk-In Counselling
Suite 200 9562 82 AVE
Edmonton, Alberta, T6C 0Z8
Phone: 780-757-0900

The Walk-In Councelling Society of Edmonton respects the privacy of visitors to our website. Personal information is only collected, used and disclosed in accordance with this Privacy Policy. Sources: Canadian Centre for Philanthropy; Reynolds, Mirth, Richard and Farmer LLP; McLennan Ross LLP; CanWest Global Communications; CKUA; ATCO Gas