Volunteer Information Form

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

Name:

Home Address:

City:

State: Zip:

Home Telephone Number:
()

Employment Information

Name of Company:

Address:

Telephone Number
( )

Fax Number:
()

Other Information

Birthday (Month & Day Only!!):

Volunteer Interest:
What would you like to do or accomplish as a volunteer?

What are your other past or current volunteer commitments?

When is the best time for you to meet for an interview or perform volunteer activities?

Mornings before
Lunch meeting
Evenings after
My schedule is flexible

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

Please complete form & mail or fax to:

Attention: Eileen Erbengi
Alzheimer�s Association, Northern Virginia Chapter
10201 Lee Highway, Suite 210
Fairfax, Virginia 22030
TEL: (703) 359-4440
FAX: (703) 359-4441

Thank you for helping make a difference!!! For more information about Volunteer Opportunities, please telephone Eileen Erbengi at the Chapter office: (703) 359-4440.