Volunteer Application Package

Becoming a volunteer

Thank you for your interest in joining our volunteer program. Volunteers are valued members of our team at the Alzheimer Society Peterborough, Kawartha Lakes, Northumberland, & Haliburton.

Becoming a volunteer involves significant time and resources from you and from the organization. For this reason, we ask that all volunteers make a long-term commitment to the program and maintain a regular volunteer schedule. Please carefully consider if you are able to make this type of commitment.

Volunteers are selected and placed according to the needs of the organization and the interests, skills, availability and suitability of each applicant. Due to the nature of work in our organization, there are limited volunteer opportunities on evenings and weekends. Please note: only applications for available volunteer opportunities will be considered, and only applicants whose skills match the needs of the organization will be contacted for an interview.

The diagram below outlines the steps to become a volunteer - it can take a few weeks to complete the process.

Mail, fax or email this form to Susan Simmons, Coordinator of Volunteer Services

To learn more please contact Susan at 705-748-5131 x230 or ssimmons@alzheimerjourney.ca

Alzheimer Society Peterborough, Kawartha Lakes, Northumberland, & Haliburton

18-360 George St N, Peterborough, Ontario K9H 7E7

TEL: (705) 748-5131 • FAX: (705) 748-6174

www.alzheimer.ca/pklnh

VOLUNTEER APPLICATION

NEW Volunteer Applicant☐ Returning Volunteer Applicant☐Date of last activity:Click here to enter a date.
Personal Information
Name: Click here to enter text.
Address:
Home Phone: Click here to enter text.	Cell Phone: Click here to enter text.
E-Mail Address*: Click here to enter text.	Preferred Contact: Phone ☐Email ☐
Date of Birth (optional): Click here to enter a date.	All applicants must be 16 years of age or older
Have you ever been convicted of a criminal offence for which a pardon has not been granted? Yes☐ No X

Emergency Contact Information
Name: Click here to enter text.	Relationship:Click here to enter text.
Home Phone: Click here to enter text.	Cell Phone: Click here to enter text.	Work Phone: Click here to enter text.

Additional Information
Languages spoken: English ☐French ☐Other ☐: Click here to enter text.
I am currently: ☐ Employed Full-Time ☐ Part-Time ☐ Student ☐ Unemployed ☐ Retired
Does your employer support you in volunteering? Yes☐ No☐
Regions of Interest: Peterborough☐ x Kawartha Lakes☐ Northumberland☐ Haliburton☐

Why did you decide to volunteer?
Click here to enter text.
Why Alzheimer Society?
Click here to enter text.
What previous work and/or volunteer experience have you had that you think might be useful?
Click here to enter text.
Please list any skills and/or hobbies:
Click here to enter text.

What type of volunteer opportunity are you interested in?
Office / Administrative Support: ☐Covering reception ☐Administration ☐Financial processing	Fundraising / Special Events: ☐Grant Proposals ☐Coffee Break Campaign ☐Donor Relations
Advisory: ☐ Policy development ☐ Governance (Board of Directors)	Planning Committee Member (specify): ☐Walk for Alzheimer’s ☐Fire Truck Pull
Education/Awareness: ☐Displays at Community Events ☐Research projects ☐Speaker’s bureau	Day-of Event Helper (specify): ☐Walk for Alzheimer’s ☐Fire Truck Pull ☐Hockey Game
Client Support*: ☐Support Group Facilitator ☐Friendly Visiting ☐Client Caller ☐Minds in Motion Program Assistant	Marketing / Communications: ☐Writing & editing skills ☐Content creation ☐Social media ☐Newsletter

*Please complete this section if you indicate interest in Client Support
Can you commit your time for a minimum of 6 months? Yes☐ No☐
Do you have access to a vehicle: Yes☐ No☐
Are you willing to travel out of your community? Yes☐ No☐
If yes, how far are you willing to travel? 50 km
Are you currently supporting someone with dementia? Yes☐ No☐
Do you have any allergies/sensitivities that would prevent you from going into someone’s home? ☐Pets ☐Scents ☐Cigarette Smoke ☐Other:_______________________
Describe your knowledge and understanding of dementia:
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Please check the day(s) and time(s) you would be available to volunteer:
Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Morning	☐	☐	☐	☐	☐	☐
Afternoon	☐	☐	☐	☐	☐	☐
Evening	☐	☐	☐	☐	☐	☐
Can you commit your time for at least 2 hours per week at a regular day/time? Yes☐ No☐

Please complete the Volunteer Reference Form on the next page.

Volunteer Reference Form

References must have known the applicant for a minimum of one year and cannot be family members, friends or reside in the same household. One reference must be related to professional/work/volunteer related experience.

Professional References Someone who has known you for at least 2 years that can speak to your work related qualities.
Name:Click here to enter text.	Email: Click here to enter text.
Home phone:Click here to enter text.	Cell phone:Click here to enter text.	Work phone:Click here to enter text.
What is your relationship to this person? Click here to enter text.
How long have you known this person?Click here to enter text.
Name:Click here to enter text.	Email:Click here to enter text.
Home phone:Click here to enter text.	Cell phone:Click here to enter text.	Work phone:Click here to enter text.
What is your relationship to this person? Click here to enter text.
How long have you known this person?Click here to enter text.

Personal Reference Someone who has known you for at least 2 years that can speak to your character.
Name:Click here to enter text.	Email: Click here to enter text.
Phone:Click here to enter text.	Relationship:Click here to enter text.
What is your relationship to this person?Click here to enter text.
How long have you known this person?Click here to enter text.

The Alzheimer Society of Peterborough, Kawartha Lakes, Northumberland, & Haliburton (ASPKLNH) is committed to protecting your personal and confidential information. Information provided during the volunteer application process will be used to determine your volunteer interests and offer appropriate volunteer opportunities.

Despite security precautions, the security of information transmitted by email cannot be guaranteed. By providing an email address on this form you are giving consent to our use of email to contact you regarding volunteering.

I give permission for the ASPKLNH to contact the references listed above in regard to my Volunteer Application by phone and/or by letter and or/by email.

By signing, I confirm that the information in this volunteer application is complete and true.

______________________________ Click here to enter a date.

Applicant Signature	Date

______________________________ Click here to enter a date.

Parent/Guardian Signature*	Date

*A parent/guardian must also sign for volunteers under 18 years of age.