Alzheimer Society North East Simcoe County
Volunteer Application Form continued............
6. Do you have your own transportation? YES NO ___________________________________________
7. Languages spoken other than English: _______________________________________________________
8. Please indicate the day(s) and time(s) you could be available to volunteer:
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Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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Saturday
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Sunday
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Morning
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Afternoon
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Evening
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9. Optional: What is your occupation and educational background? ____________________________________
_____________________________________________________________________________________
10. Please identify any medical conditions/allergies we should be aware of during your
volunteering duties? ____________________________________________________________________
___________________________________________________________________________________
11. Whom should we contact in case of emergency:
Name/relationship ___________________________________ Phone:______________________
Name/relationship ___________________________________ Phone:______________________
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12. Please list 3 references we may contact who have known you for more than 2 years. (Work, Professional,
and/or Volunteer. Only one personal reference.)
Name/Title Address (include Postal Code) Phone
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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I give permission for the Alzheimer Society of North East Simcoe County to contact my references and
have a Volunteer Reference Form completed.
Volunteer Signature ___________________________________ Date ____________________
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Thank you for your interest.
All information submitted herein is considered Confidential by the
Alzheimer Society of North East Simcoe County
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