Our PLACE Volunteer Information Form

Our PLACE Volunteer Information Form

The mission of Our PLACE, an adult day center for seniors with mild to moderate Alzheimer’s or dementia, is to improve quality of life by providing a day program of care, social interaction, and therapeutic activities in a safe and nurturing environment. Much of what Our PLACE does is fueled by volunteers – If you would you like to be part of the Our PLACE team and share your time and talents in creating Moments of Joy for our participants and their families, please fill out this form and someone will be in contact with you soon.
Date

MonthDayYear
Date
Name

First NameLast Name
Are you over the age of 18?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name & Phone
How did you hear about our program?
On which days are you available?

MondayTuesdayWednesdayThursdayFriday
Morning or afternoon?

MorningAfternoonNo preference
I'm interested in:

Regularly working with participants (Volunteer Program Assistant)Occasionally substituting for those working with participantsSharing special skills/activities with participants
Special skills or areas of interest include (choose all that apply):

CookingBakingCake/cookies decoratingSinging/sing-alongMusical instrumentDanceQuiltingSewingCrocheting/knittingEmbroideryArtPuzzlesCraftsCeramicsMosaic tileFloral arrangementsShuffleboardBoard gamesBingo/chess/checkersSportsPhotographsYoga/Tai ChiExercise/MovementReminiscenceOther
Administrative/Business

Clerical/office supportMarketingGrant writingFundraisingEvent PlanningInformation TechnologyGraphics designOther
Should be Empty: