ALZHEIMER SOCIETY

							                             VOLUNTEER APPLICATION FORM

Name: _________________________________________                         Date: _____________________

Telephone: (Home): ________________ (Work): _______________ (Cell): ________________

 Please circle the phone number you would prefer us to call you at. If there are any confidentiality issues
associated with any of these phone numbers (or address, email, etc), please let us know.

Address: _______________________________________________________________________
                   Street                              City             Province              Postal Code

Email: ___________________________________ is email a good way to reach you? Yes / No

1. How did you hear about the Alzheimer Society?
   Alzheimer Society Newsletter: ____ Newspaper: ____ Radio:____ Friend / Family: ____
   Volunteer Thunder Bay:____ TV:____ Other:____________________________________

2. Are you interested in the Society as a: (Feel free to check more than one)
    Caregiver / Family member  Health Care Professional
    Person with Alzheimer’s disease or a related dementia  Other

3. Are you currently a member of the Alzheimer Society of Thunder Bay? Yes / No

4. What are the main reasons why you would like to volunteer with the Alzheimer Society?




5. Are you currently:
    Employed full-time  Employed part-time Employer Name: ______________________
    Seeking Employment      Retired           Student
    Other: __________________________________________________________________

6. What is your educational/career background? ___________________________________
      _______________________________________________________________________

7. Do you speak or write a language other than English? Yes / No
   Please Specify: _____________________________________________________

7. Do you have access to a vehicle and a valid driver’s license?                   Yes / No

8. Have you done volunteer work before? Yes / No    (If Yes, please list)
      __________________________________________________________________________
      __________________________________________________________________________
      __________________________________________________________________________
                                                    2




9. Please indicate what sort(s) of volunteering you are particularly interested in:
    Office: telephone, mailings, general clerical duties, computer work i.e., data entry, word processing.
    Special Event Planning: Walk for Memories, Coffee Break, Alzheimer Rendezvous, etc.
    “Day of Event” Volunteer: Coffee Break Day, Walk for Memories, BBQ, “on-call”
    Public Awareness: displays, presentations, videos, public speaking
    Driver: Coin Box Program, special events, deliveries
    Family Support: telephone program, support groups
    Other: _____________________________________________________________

10. When are you available to volunteer?
    Mornings:          Monday        Tuesday            Wednesday  Thursday            Friday
    Afternoons:        Monday        Tues day           Wednesday  Thursday            Friday
     Week Nights        Weekends       Other: _____________________________

11. Are you involved in other clubs, groups or organizations? Yes / No (If Yes, please list)
    __________________________________________________________________________
    __________________________________________________________________________
    __________________________________________________________________________

12. How long can you commit your volunteer services?
      Short Term (Under 3 months)    Long Term (Over 3 months)                   Unsure

13. Contact person in case of emergency:
     Name: __________________________________ Telephone: ________________________
     Relationship: _____________________________

14. References: (No more than one reference should be from a family member)

Name: ______________________________ Telephone: _____________________________
Relationship: ___________________________________________________________________

Name: ______________________________ Telephone: _____________________________
Relationship: ___________________________________________________________________

Name: ______________________________ Telephone: _____________________________
Relationship: ___________________________________________________________________

I give permission to contact the above reference people:

SIGNATURE: __________________________________________________

Thank you for your interest in the Alzheimer Society of Thunder Bay.