Name: * Apt:
Address: * Postal Code: *
Home Phone: Work Phone:
Fax: E-mail: *

1. Please indicate which volunteer opportunities you would be interested in:

a) Working on a committee to plan and organize events
b) Public awareness displays and health fairs
c) Phone solicitation, donation collection and other fund raising activities
d) Helping during the Society's events (Walk for Memories, Coffee Break)
e) Providing leadership on our Board of Directors and commitees

2. We are looking for a minimum commitment of four months. The number of hours will vary depending on the volunteer assignment.

If you're interested in helping in the office, please indicate the times when you are available for volunteering:
  Monday Tuesday Wednesday Thursday Friday
Morning
Afternoon

If you're interested in any other opportunities, please indicate the times when you are available for volunteering:

3. How much time would you be able to commit to volunteering?

Hours Per Week  Hours Per Month 
When Needed Other (Please Specify) 

4. Have you ever had experience with Alzheimer Disease or a person with Alzheimer Disease? If yes, please describe:

5. Have you volunteered with other community organizations? If yes, please describe:

6. What would you like to accomplish as a volunteer for the Society?

7. How did you hear about the volunteer opportunities?

a) Internet
b) Through a friend
c) Newspaper
d) Radio
e) Television
f) Volunteer Center of Durham Region
g) Other (Please describe)

8. Do you have a drivers licence and access to a vehicle?

Yes No

9. References (other than family members)

Name: * Name: *
Address: * Address *
Telephone: * Telephone: *
Relationship: * Relationship: *

I give permission to the Society to contact my references:

Yes No

Please note: All volunteers are required to sign a confidentiality form at their initial interview.

(* denotes required field)