1. PERSONAL INFORMATION
Submission Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number/Whats App
*
-
Country Code
-
Area Code
Phone Number
City & Country of Residence
*
Languages Spoken
*
Preferred Contact method (Select each that apply)
2. VOLUNTEER INTEREST & AVAILABILITY
Please describe how you would like to be involved and mention your interest and experience
*
Availability
*
Year round
WInter Period
Summer Period
Other
Please indicate the estimated hours you are able to offer monthly
*
3. AREAS OF INTEREST/VOLUNTEER ROLES
Please check any areas you are interested in supporting.
*
Please describe any relevant skills, experience or interest:
*
4. FUNDRAISING & IN-KIND DONATION INTEREST
Would you be interested in supporting fundraising efforts?
*
YES
NO
MAYBE
If you answered YES on the previous question, please check all that apply.
Possible in‑kind donation items or services you could offer (optional)::
5. EXPERIENCE WITH DEMENTIA OR AGING POPULATIONS
Have you had personal or professional experience with dementia, memory loss, or elder care?
*
YES
NO
If you answered YES, please share:
Thank you for your interest in supporting this project. Please tell us what motivates you to support the Lakeside Memory Neighborhood Project? Enter any questions, concerns or comments below.
*
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