2013 Walk to End Alzheimer's

Volunteer Form

* required information
Registration 
Registration Information
At which Walk would you like to volunteer?:*
If you are volunteering with a group, please provide the name of the group here::
First Name:*
Last Name:*
Email:*
Phone:*
Birth Date:*(mm/dd/yyyy)
Address Line 1:
Address Line 2:
City:
State:
ZIP/Postal Code:
Please choose the most appropriate connection you have to Alzheimer's disease: I have received a diagnosis of Alzheimer’s disease
I have/had a family member with Alzheimer’s disease
I am a caregiver for someone with Alzheimer’s disease
I have a friend with Alzheimer’s disease
I have a professional interest in Alzheimer’s disease
I do not know anyone with Alzheimer’s disease
Have you ever volunteered with us before?: Yes
No
Would you like to learn more about other volunteer opportunities?: Yes
No
In case of an emergency, please contact::*
Emergency contact phone::*
Emergency contact relationship to volunteer::*
Assumption of Risk, Release and Permission::* PLEASE CHECK THIS BOX IF YOU AGREE TO THE FOLLOWING STATEMENT:In consideration of being allowed to participate as an Alzheimer’s Association event volunteer, I hereby expressly assume all risks of personal injury, death or property loss arising in any way out of my participation. I represent that I am physically fit and able to participate in this event. I hereby release and agree not to sue Alzheimer’s Association, the chapters, their respective officers, directors, volunteers, employees, sponsors and agents, from or in connection with any and all liability and claims arising out of my participation in this event. I grant full permission to the organizers of this event to use and publish my name and image as a participant through photographs, video and other recordings.
Fees
$0.00 Free
Donation
Amount:$