Volunteer Application

Volunteer Application Form

For questions or concerns, please contact the Coordinator of Volunteer programs at swatson@alzheimerniagara.ca
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender

MaleFemaleOther
I am 18 years old or older*

YesNo
Why would you like to volunteer for the Alzheimer Society?
What would you like to gain from your volunteer experience?
How did you hear about the Alzheimer Society?
As an organization we are open to diversity and inclusion. Are there any accommodations that are required for you to fulfill the volunteer position?
Which volunteer opportunities are you interested in?

AdministrationBingoCommitteeEducationFundraisingGroup Social RecreationMeaningful VisitsRecollectionsTele-CareOther

Please indicate when you are available to volunteer:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning
Afternoon
Evening

Please indicate where you are willing to volunteer:

St. CatharinesNiagara FallsThoroldWellandFonthillWainfleetGrimsbyFort EriePort ColborneNiagara-on-the-LakeLincolnWest LincolnOther
Length of commitment:

Single event3 - 6 months6 - 12 monthsSummerOngoing
Languages Spoken

EnglishFrenchOther
Please provide a professional and personnal reference we have permission to contact.

*Please exclude immediate family members
Reference #1
Name

First NameLast Name
Email
example@example.com
Daytime Phone

Area CodePhone Number
Relationship
Reference #2
Name

First NameLast Name
Email
example@example.com
Daytime Phone

Area CodePhone Number
Relationship
Mailing List*

Yes, add me to your e-mail list so I can receive the Alzheimer Society of Niagara Region's "The Voice" newsletter for all news and updates from the SocietyYes, add me to your e-mail list so I can receive the Alzheimer Society of Niagara Region's Volunteer newsletter for all volunteer opportunities and updates from the SocietyNo, do not add me to your e-mail list
Authorization for the collection of personal information

We require your knowledge and consent to collect, use and disclose your personal information. The information you provide on this volunteer document will remain confidential, however but may also be shared with relevant organizations to obtain an appropriate volunteer role. Email address may be collected with permission for use in the communicating training information, agency closures, and communication documents. All information collected in handled with the guidelines for the collection, use and disclosure of personal information under Personal Information Protection and Electronic Documents Act (PIPEDA) and the Personal Health Information Protection Act (PHIPA).

I attest that the information provided in this application is both true and correct.
Signature*

Clear
Date*

DayMonthYear
Date
Enter the message as it's shown*
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Volunteer Application Form