Volunteer Information Form

Volunteers are the heart of our Chapter and we could not provide the important services and support to the community - families, caregivers, professionals - without people like you. We appreciate your interest in our organization and we are grateful for your support of our mission.

(please type answers, print this form, & mail or fax to the Alzheimer's Association)

Date:

Date of Birth:

Mr. and Mrs.     Mr.     Mrs.     Ms.     other:    

First Name(s):

Last Name(s):

Mailing Address: Home     Work    

City:

State: Zip:

Home Telephone Number:
()

Work Telephone Number
( )

E-mail:

Fax:
()

Emergency Contact Person:

Relationship:

Emergency Contact Telephone Number:
()

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, 1 year commitment)
Administrative/Clerical
Bulk Mailing
Computer - Data Entry
Computer - Word Processing
Computer - Desktop Publishing
Grassroots Lobbying via E-mail
Health Fairs (training required)
Outreach Team Leader
Outreach Team Member
Public Relations
Speakers' Bureau (training required)
Special Events/Fundraising
Support Group Leader (training required, 2 year commitment)

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 ()

Thank you for volunteering your time, talents & service to the Alzheimer�s Association.

Please complete form & mail or fax to:

Attention: Carolyn Thomas
Alzheimer�s Association, National Capital Area
11240 Waples Mill Road, Suite 402
Fairfax, Virginia 22030
TEL: (866) 259-0042
FAX: (703) 359-4441


© 1997 - 2001 Alzheimer's Association, National Capital Area. All rights reserved.


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