Volunteer Application Form

VOLUNTEER APPLICATION

Minds in Motion Assistant
Volunteers are important to Alzheimer Society Waterloo Wellington. We will do our best to place all volunteers who apply. However, Alzheimer Society Waterloo Wellington provides services to a vulnerable sector of our community and while all offers to volunteer are appreciated by our chapter, we also recognize our moral and legal obligation to thoroughly screen volunteer applicants.
For additional information about our volunteer application process or if you have any questions or concerns our Volunteer Coordinator would be happy to discuss them with you. Please note that the timeline for being placed, once your interview has taken place, can be from 4 to 6 weeks (allowing sufficient time for reference checks, etc.)

Please note that our positions are reliant on verbal communication.

Volunteers must be fluent in spoken English (CLB level 10+).
Name*

First NameLast Name
Preferred Name
Preferred pronouns
Other pronouns:
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Preferred Method of Contact*

EmailPhone (Call)Phone (Text)
Emergency Contact Name*

First NameLast Name
Relationship with Emergency Contact*
Such as wife, son, partner, friend, etc.
Phone Number*
Please enter the phone number your emergency contact would be most easily contacted through.
Are you a client or caregiver registered with Alzheimer Society Waterloo Wellington? (For example, do you receive social work support, take part in recreational or education programs etc.?)

YesNoUnsure
Languages Spoken other than English
How did you find out about Volunteering at Alzheimer Society Waterloo Wellington?*
Skills Summary
Please attach a copy of your resume OR complete the Skills Summary sections below identifying the organizations, role and length of service that are relevant to the volunteer role you are applying for.

Cancelof

Skills Summary Employment History
Employment History Position #1
Organization
Number of Years
Employment History Position #2
Organization
Number of Years
Employment History Position #3
Organization
Number of Years

Skills Summary Educational Background
Educational Background Program #1
School
Last Level Completed
Educational Background Program #2
School
Last Level Completed
Educational Background Program #3
School
Last Level Completed

Skills Summary Volunteer Experience
Volunteer Experience Position #1
Organization
Number of Years
Volunteer Experience Position #2
Organization
Number of Years
Volunteer Experience Position #3
Organization
Number of Years

How often would you be available to volunteer?*

OccasionallyRegularlyWeeklyMonthly
We ask that volunteers commit to at least 8 weeks of volunteering. Are you able to commit to this?*

YesNo
If you cannot commit to weeks of volunteering, can you tell us how much you could commit to?

When you consider your current schedule and commitments, what is your availability? If unavailable, leave blank. *

	Mon	Tues	Wed	Thurs	Fri
Please select all that are applicable

Do you identify as an equity seeking group? ie:2SLGBTQIA+, First Nations, Inuit, Metis, etc.

YesNo
In 2026, Alzheimer's Society Waterloo Wellington will be starting a new program called "The Social". This will be a 3 hour program for people living with dementia. "The Social" will offer opportunity for engagement, stimulation, and socialization for the attending client, while also offering the care partner time for individual needs. The activities offered within the group are focused on stimulating the six domains of wellbeing which include: cognitive, emotional, social, spiritual, vocational, and physical.

If you are interested in receiving more information about volunteering for "The Social", please indicate below.
Yes, please send me more information about volunteering for The Social
Please note that placement with Alzheimer Society is at the agency’s discretion.
References
List two professional references that we may contact after a successful interview. It is preferred that at least one reference be a community leader that has had a supervisory relationship with you. Examples may include a current or former employer, volunteer manager or teacher.

References from family members will not be accepted.

Reference #1
Reference One Name*

First NameLast Name
Email
example@example.com
Relationship with Reference*
Such as supervisor, teacher, volunteer manager
Years Known*
Such as supervisor, teacher, volunteer manager

Reference #2
Reference Two Name*

First NameLast Name
Email
example@example.com
Relationship with Reference*
Such as supervisor, teacher, volunteer manager
Years Known*
Such as supervisor, teacher, volunteer manager

I give my permission for Alzheimer Society Waterloo Wellington to contact the above two references in regard of my application to volunteer.
Signature*

Clear
Are there any special skills or talents that you would like to share while volunteering?
Is there anything else you would like us to know about you?
Once your application has been reviewed, you will be contacted to schedule an interview.

For more information about volunteering at Alzheimer Society Waterloo Wellington, contact Tom Connelly by emailing thomas@alzheimerww.ca or by telephone at 519-742-8518, ext. 2028.

Disclaimer: Alzheimer Society Waterloo Wellington may use and disclose your personal information collected and/or obtained during the volunteer recruitment process for the purpose of determining your suitability for volunteering. If volunteering, your personal information will be incorporated into your volunteer file and may be disclosed for the purpose of administe ring your volunteer service.
Signature

Clear
Should be Empty:

VOLUNTEER APPLICATION

Skills Summary

References