Alzheimer Society : Peterborough, Kawartha Lakes, Northumberland & Haliburton

Volunteer Information Form

Name:

Address:

Telephone:
(H)
(B)

May we contact you at work? Y N

Best time to contact you:

Morning

Afternoon

Evening

E-mail Address:

For insurance purposes, please provide your date of birth (M/D/Y)
/ /

Emergency Contact Name:

Telephone:
(H)
(B)

Are you fluent in any languages other than English? If yes, please indicate which:

How did you hear about the Alzheimer Society?

Have you been involved with other volunteer services in the community?
Y N

If yes, please describe:

Do you prefer to volunteer during:

Morning

Afternoon

Evening

Special skills, interests, hobbies:

Do you have previous awareness of the effects of Alzheimer's Disease/Dementia?
Y N

If yes, please describe:

Have you worked with people who have Alzheimer's Disease/ Dementia?
Y N

If yes, please describe:

Briefly explain why you chose this volunteer respite position:

Do you have preferences or concerns as to a client's gender?

What type of transportation do you use?

Own Vehicle

City Transit

Other

A face-to-face interview, Police Reference Check (CPIC) and Volunteer Training will be required.

Please Provide three (3) references (non-relatives)

Name:

Telephone:

Relation to applicant:

Name:

Telephone:

Relation to applicant:

Name:

Telephone:

Relation to applicant:

Fill in the form then print it immediately or print the blank form.

I give my permission for the Alzheimer Society of Peterborough and Area to contact the above references in regard to my application for volunteer placement:

Volunteer's Signature

Date

Interview's Signature

Date

Thank you for your interest in the Friendly Visiting Program. Please mail the completed form to the address below, or drop it by our office. We will contact you to arrange a time to meet to discuss your application. We appreciate your interest and support!

The Alzheimer Society of Peterborough & Area
183 Simcoe Street
PETERBOROUGH, ON, K9H 2H6.
ATTN: Betty Batten

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