FORMULAIRE D`INSCRIPTION D`UN ACCOMPAGNATEUR

PGD / GDP
SSP / ECS
FORMULAIRE D’INSCRIPTION D’UN ACCOMPAGNATEUR
COMPANION REGISTRATION FORM
S.V.P. ÉCRIRE EN LETTRES MOULÉES / PLEASE PRINT
IDENTIFICATION DU CANDIDAT / IDENTIFICATION OF APPLICANT
Nom / Name
Prénom / Given name
D ate
de
nais sance / Date of birth
(A Y / M M / JD )
/
Adresse / Address
Ville / City
 Maison /  Home
 Travail /  Work
(
(
)
)
C ode Postal / Postal Code
 C ellulaire /  Cellular
(
/
C ourriel / E-mail
)
INFORMATIONS PERSONNELLES / PERSONAL INFORMATIONS
Langues parlées /
Spoken languages:
Scolarité complétée /
Academic level completed:
Étudiant / Student
Français / French
Anglais / English
Autres / Others
_____________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Nom de l’école / Name of school
Travailleur / Worker
Retraité / Retired
________________________________________________
Profession / Occupation
________________________________________________
Dernier employeur / Last employer
# D’assurance sociale, si vous accompagner des ré sidents sous curatelle / Social insurance #, if you accompany re sidents unde r
public curator ____________________________________________________________________________________ __
Avez-vous un problème médical ou une condition physique qui pourrait influencer votre travail? /
Do you have any physical or medical condition that could inhibit your work?
oui / yes
Si oui, spécifiez (incapacités, médicaments…) / If yes, specify (incapacities, medication…)
non / no
__________________________________________________________________________________________________
Allergies / Allergies
Référence personnelle /
Personal reference
Référence professionnelle /
Professional reference
Si oui, spécifiez / If yes, specify
__________________________________________________________________________________________________

___________________________________________________________
(
)_____________________

___________________________________________________________
Personne à joindre en cas d’urgence / In case of emergency, contact:
(
)_____________________

(
)_____________________
Pourquoi voulez-vous devenir accompagnateur / Why do you want to be a companion ?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
March 2015
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EXPERIENCE D’ ACCOMPAGNATEUR / COMPANION EXPERIENCE
Avez-vous une expérience antérieure comme accompagnateur? / Do you have any previous companion experience?
Si oui, spécifiez (tâches, organisation…) / If yes, specify (tasks, organization…)
oui / yes
__________________________________________________________________________________________________
non / no
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Je déclare par la présente que les renseignements ci-dessus sont vrais et complets. Je comprends
qu’une fausse déclaration peut mettre un terme au processus d’étude de ma ca ndidature comme
accompagnateur ou entraîner mon renvoi. Je comprends également qu’une vérification de mes
antécédents est nécessaire.
I hereby declare that the above information is true and complete. I understand that a false statement
may disqualify me from further consideration as a companion or result in dismissal. I also understand
that a background check is required.
Signature:
_____________________________________________
Date: _________/ ___________/ ________
Année / Year
Mois / Month
Jour / Day
EMBAUCHÉ COMME ACCOMPAGNATEUR POUR / HIRED AS A COMPANION FOR:
Nom du résident / Name of resident :_________________________ #de chambre / Room # :________________
Employeur / Employer:_____________________________________  __________________________________
Date d’embauche / Date hired:______________
Date de depart / Date terminated:______________
C ommentaires / C omments:_________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Horaire / Schedule:
Lun / Mon
Mar / Tue
Mer / Wed
Jeu / Thu
Ven / Fri
Sam / Sat
Dim / Sun
Tâches / Tasks
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
SC/LPDM – 07/15
March 2015
2