Alzheimer Society London and Middlesex

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

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Note: A police records check less than 6 months old will be required for all volunteers after a successful interview

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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

Preferred Pronoun *

She/HerHe/HimThey/ThemOther

If other, please state

Date of Birth *

MM / DD / YYYY

Emergency Contact Name *

Emergency Contact Phone Number *

( ) -

Medical Conditions/Special Accommodations

Please feel free to only disclose what you are comfortable sharing with ASLM and feel necessary that we know for volunteer and safety purposes.

Highest Level of Education *

High SchoolUniversityCollegeOther

If other, please state

Area of Study or Employment *

Current employer/school/organization *

Do you speak another language/dialect? *

YesNo

In addition to English

If yes, which language(s)/dialect(s)?

Are you fluent in ASL (American Sign Language)? *

YesNo

Do you have access to a vehicle? *

YesNo

Have you ever volunteered before? *

YesNo

If yes, how long have you volunteered?

Are you comfortable with online programming? *

YesNo

Relevant work and/or volunteer experience *

Can you commit to 3 months of volunteering? *

YesNo

A minimum 3-month commitment is required for all volunteers. For the In-Home Recreation Program, there is a 6-month minimum commitment.

Why would you like to volunteer for ASLM? *