North VictoriaHealthy Communities Coalition |
Too often we hear only about that which is lacking in our communities or the needs. We feel that
it is time to begin to map the assets or good things in our area. Our initial task is to map the
capacities of individuals. That is why we are asking you to complete the following so that a
database can be developed and made available locally.
One of the most important features of this type of community survey is the need for those completing it to include their name, address and phone number. Once the database is developed then local residents, businesses and community groups can access this information for possible employment, training assistance and volunteer activities. Please note that this is for residents of North Victoria County only
( Burnt River , Coboconk, Kinmount, Norland, Kirkfield and surrounding areas )
In appreciation of your assistance, we will be making a
draw of all completed surveys
that include your name, address and phone.
There will be
25 prizes of a $ 20.00 cash gift certificate
to be used at a local business of your choice
Draw date: September 30th, 1997
Thank you for you assistance. If you require further information or are in need of additional
surveys, please contact us at 454.8875 or 1.888.454.8875 (toll free).
Sincerely,
Peter Jones, Chair
PLEASE CHECK ALL THE SKILLS THAT YOU HAVE Health/Nursing Care ____Caring for the Elderly ____Caring for the Mentally Ill ____Caring for the Sick ____Caring for the Physically Disabled or Developmentally Disabled ____Licensed (RN, RNA, etc.) ____C.P.R. Trained
If any of the above, then what kind of care was provided ?
____Bathing/Feeding ____Preparing Special Diets ____Exercising and Escorting ____Grooming ____Dressing ____Comforting/Visiting Beauty and Body Care ____Massage ____Manicurist ____Aroma therapy ____Hair Dressing/Perms/Cutting ____Reflexology ____Exercise ____Herbs ____Alternative Health Products ____Weight Management ____Nutrition Construction ____Build House/Garage/Tool Shed ____Build stairs/Porch ____Painting ____Building Demolition ____Knocking Out Walls ____Wall Papering ____Installing Doors/Screen Doors ____Upgrading Kitchen/Bathroom ____Building Room Additions ____Installing Drywall & Taping ____Bricklaying & Masonry ____Cabinetmaking
____Furniture Making ____Installing Insulation ____Plastering ____Blueprint Reading or Drawing ____Soldering & Welding ____Concrete Work (Sidewalks, Driveways) ____Installing Floor Coverings, Tile, Vinyl, Carpets, etc. ____Heating/Cooling System Installation ____Putting on Siding ____Repairing Chimneys ____Installing Windows ____Building Swimming Pools ____Roofing Installation/repair ____Carpentry Skills Maintenance ____Window Washing ____Floor Waxing or Mopping ____Washing and Cleaning Carpets/Rugs ____Routing Clogged Drains ____Using a Hand truck in a business ____Caulking ____Cleaning Chimneys (chimney sweep) ____General Household Cleaning ____Fixing leaky Faucets ____Mowing Lawns, Pulling Weeds ____Planting & Caring for Gardens ____Pruning Trees & Shrubbery ____Cleaning/Maintaining Swimming Pools ____Floor Sanding or Stripping ____Wood Stripping/Refinishing ____Cleaning Rain Gutters Repair ____Repairing/Installing Locks ____Regrouting Tile Work ____Plumbing Repairs ____Electrical Repairs ____Repairing Drywall, Stucco, etc. ____Repairing Chimneys ____Roofing Repair ____Repairing Heating/Cooling System ____Refurbishing/Reupholstering Furniture ____Repairing Radios, TVs,VCRs,Tape Players ____Repairing Small Appliances, Clocks, Toasters, Irons, etc. ____Repairing Large Appliances (Refrigerator, Stove, Washer, Dryer) ____Assembling Items (such as toys, packaged items, etc.) Food ____Catering ____Serving Food ( Over 10 People ) ____Preparing Meals (Over 10 People ) ____Clearing/Setting Tables (Over 10 People) ____Washing Dishes (Over 10 People) ____Bartending ____Meal Planning ____Nutritionist ____Meatcutting/butcher ____Grill Cook ____Baking/Cake Decorating ____Specialty Recipes Child Care ____Caring for Babies (under 1 year) ____Caring for Children (1-6 year olds) ____Caring for Children (7-13 year olds) ____Taking Children on Field trips ____Played Games With Children ____Read Stories to Children ____Teach Kids to Make a Craft ____Change Diapers ____Care for a Sick Child ____Perform Infant CPR? Transportation ____Driving a Car ____Driving a Van ____Driving a Bus ____Driving a Taxi ____Driving a Tractor Trailer ____Driving a Commercial Truck ____Driving a Vehicle ____Delivering Goods/Hauling ____Operating farm Equipment ____Driving an Ambulance Auto Mechanics ____Repairing Automobiles ____Repairing Trucks/Buses ____Repairing Auto Bodies ____Change Tires ____Change Oil/Oil Filter ____Tune Up an Engine ____Replace Windshield ____Install Car Stereo/Speakers ____Auto Detail ____Body Work ____Replace Battery ____Repair Brakes Operating Equipment/ Heavy Machinery ____Operate a Forklift ____Operate a Dump Truck ____Operate a Crane ____Operate Farm Equipment ____Operate Commercial Food Preparation Equipment ____Operate an Assembly Line ____Operate a Sewing Machine Supervision ____Writing Reports ____Filling out Forms ____Planning Work for Other People ____Manage a Project ____Organizing a Fundraiser ____Directing the Work of Other People ____Making A Budget ____Keeping Records of All Your Activities ____Interviewing People Sales ____Operating a Cash Register ____Customer Service ____Selling Products Wholesale or for Manufacturer. If yes, which products? ____Selling Products Retail. If yes, which products? ____Selling Services (Homemade Items, Food, Jewelry, Clothes, Etc.) ____How have you sold these products or services? (check mark, if yes) ____Door to Door ____Telephone ____Mail ____Store ____Home Music ____Singing ____Play an Instrument (Which Instrument/s?) ____D.J.(Disc Jockey an Event)________________________________ Security ____Neighborhood Watch ____Guarding Residential Property ____Guarding Commercial Property ____Guarding Industrial Property ____Armed Guard ____Crowd Control ____Ushering at Major Events ____Installing Alarms or Security Systems ____Repairing Alarms or Security Systems ____Firefighting ____Community Policing Other ____Upholstering ____Sewing ( By Hand) ____Dressmaking ____Crocheting ____Knitting ____Tailoring ____Assembly Line ____Laundry, Ironing ____Moving Furniture or Equipment to Different Locations ____Managing Property ____Assisting in the Classroom ____Phone Surveys ____Jewelry or Watch Repair ____Plant/Animal Farming ____Forestry ____Fisheries ____Trapping/Hunting Office ____Typing (words per minute_______) ____Operating Adding Machine/ Calculator ____Filing Alphabetically/Numerically ____Taking Phone Messages ____Writing Business Letters (not typing)____Receiving Phone Orders ____Operating Switchboard ____Keeping Track of Supplies ____Shorthand or Speedwriting ____Bookkeeping ____Entering Information into Computer ____Word Processing ____Computer Skills ____Data Base Management ____Telecommuting ____WWW pages/homepages Are there any other skills that you have which we haven't mentioned? ___________________________________________________________________
Priority Skills
1. When you think about your skills, what three things do you think you do best? a)______________________________________________ b)______________________________________________ c)______________________________________________ 2. Which of all your skills are good enough that other people would hire you to do them? a)______________________________________________ b)______________________________________________ c)______________________________________________ 3. Are there any skills you would like to teach? a)______________________________________________ b)______________________________________________ c)______________________________________________ 4. What skills would you most like to learn or improve? a)______________________________________________ b)______________________________________________ c)______________________________________________
Have you ever organized or participated in any of the following community activities (Place check mark if yes) ____Scouts/Youth Groups ____Church Fundraisers ____Bingo ____School-Parent Associations ____Sports Teams ____Camp Trips for Kids ____Field Trips ____Political Campaigns ____Block Clubs ____Community Groups ____Rummage Sales/Yard Sales ____Church Events ____Community Gardens ____Neighborhood Organization ____Other Groups or Community Work?__________________________________ Experience A. Business 1. Have you ever considered starting a business Yes________No____ If yes, what kind of business did you have in mind? 2. Did you plan to start it alone or with other people? Alone_____Others_____ 3. Did you plan to operate it out of your home? Yes_____No_____ 4. What obstacle kept you from starting the business? 5. Do you think that there are opportunities for self-employment in this community? Yes_____ No_____ 6. Have you ever received self-employment training? Yes____No____ 7. Are you interested in self-employment training? Yes____No____ B. Business Activity 1. Are you currently earning money on your own through the sale of services or products? Yes__________No_______. 2. If Yes, what are the services or products you sell? 3. Whom do you sell to? 4. How do you get customers? 5. What would help you improve your business? C. Employment 1. Are you currently employed? Yes____No____ 2. If you are already employed, would you like to improve or otherwise change your current employment status? Yes____No____ 3. If you are not employed, would you like to become employed or otherwise change your current status? Yes____No____ 4. What kinds of changes would you like to make? 5. What kind of assistance would help you to accomplish your goals? THE "VILLAGE WELL" CONSENT FORM
In order to have your capacities used, abilities expressed and gifts given, please be sure to fill out this consent form.
Building Communities From the Inside Out states "Ancient villages often centered their lives around the "village well." The well was much more than a place which offered water; it was a nerve center for the entire community, a place where gossip, stories, and information of all kinds were exchanged." The NVHCC plans to develop an electronic "Village Well" with the ability to connect people together, to connect people and business, and to connect people with services..
NAME(S) __________________________________________________________
ADDRESS __________________________________________________________
__________________________________________________________
AGE(S) _________________________________
(If desired, use teens, 20s, 30s, 40s, etc.)
SEX (Please indicate Male or Female for each respondent)
PHONE _______________ DATE _______________
SIGNATURE(S) _______________________________________________________
2nd SIGNATURE _______________________________________________________
Signature of Parent/Guardian Required if under 18 Thank you for your assistance and good luck on the draw!