Volunteer Information Form

Title Mr.Dr.Mrs.Ms.
*First Name(s):

*Last Name(s):

*Email address:

*Mailing Address: Home     Work    

*City:

*State: *Zip:

*Home Telephone Number:

Work Telephone Number

Cell Phone Number

Fax:

*Emergency Contact Person:

*Relationship:

*Emergency Contact Telephone Number:

*Indicate times available:

weekdays
evenings
weekends

Do you know someone with Alzheimer's disease or a related disorder?

spouse
parent
grandparent
sibling
friend
other:

*I am interested in volunteering for the following:
Helpline (training required)
Administrative/Clerical
Bulk Mailing
Computer - Data Entry
Computer - Word Processing
Computer - Desktop Publishing
Grassroots Lobbying via E-mail
Health Fairs
Outreach Team Leader
Outreach Team Member
Public Relations
Speakers Bureau (training required)
Special Events/Fundraising
Support Group Leader (training required, 2 year commitment requested)

Please indicate other interests you may have:

Background

*What experiences (if any) do you have working with someone with Alzheimer's disease or a related disorder?:

*Why are you interested in volunteering with the Alzheimer's Association?

*In what areas do you possess special skills or talents?

*What do you like to do in your leisure time?

*What previous or current volunteer experiences have you had?

*What is your educational background?

*What languages (if any other than English) do you speak?

*If presently employed, please provide your employer's name, address and telephone number. Describe your duties and responsibilities?

*Please provide two references of persons who have worked with you or have known you for at least one year:

Name: and Telephone

Name: and Telephone