ASLM Volunteer Signup

Thank you for your interest in volunteering for Alzheimer Society London & Middlesex. Please complete and submit the following application.

*NOTE: Social Recreation Programs run during ASLM office hours; If you are interested in Social Recreation Programs, you MUST have some availability Monday – Friday, between 10 am and 4:30 pm, as that is when those programs take place. Please see the program guide or the ASLM website for timing details of specific programs. Social Recreation Programs do NOT run evenings and weekends.

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Name: Email: Comment:

Email Address *

*Note: Students at UWO please do not use school email as we often have issues with this mail system

First Name *

Last Name *

Phone Number *

Address *

Street Address Address Line 2 City State/Prov/Region Postal/Zip Country

Emergency Contact Name *

Emergency Contact Phone Number *

( ) -

Current employer/school/organization: *

Why would you like to volunteer for ASLM? *

Relevant work and/or volunteer experience *

Other than English, what languages do you speak? *

Do you have access to a vehicle? *

YesNo

Reference #1: Name, Relationship to You *

Reference #1: Contact Info (Phone & Email) *

Reference #2: Name, Relationship to You *

Reference #2: Contact Info (Phone & Email) *

I am available at these times of day:

ie. mornings, afternoons, evenings/weekends, variable (explain)