EmailMeForm
Volunteer Companion Program - Volunteer
Thank you for applying to be a Volunteer Companion. Once submitting your application, the Volunteer Companion Program Coordinator will contact you to begin the training process.
Name
*
First
Last
Email
*
Phone Number
*
###
-
###
-
####
Date of Birth (DD/MM/YYYY)
*
You are
*
Employed
Other
Retired
Student
Can you commit your time for a minimum of 6 months?
*
Yes
No
Can you commit a minimum of 1 hour per week at a regular day and time?
*
Yes
No
Do you have any experience in interacting or working with persons living with dementia? If yes, in what capacity?
*
Do you prefer to visit with the Participant:
*
In person
Virtually
Do you prefer to visit:
*
A Man
A Woman
No Preference
Are you willing to drive out of your community to visit someone in a neighboring town/ rural area?
*
Yes
No
If yes, how far would you be willing to go?
Do you have any allergies or sensitivities? (pets, scents, cigarette smoke, etc.)
*
Do you have any religious affiliations or other group affiliations?
*
Do you have any pets? If yes, what kind?
*
Languages spoken/written other than English
Please share any additional information that you believe could be beneficial for us in forming a match.
REFERENCES:
Please provide the names of 2 people who are not relatives and have known you for at least two years that the Alzheimer Society of PEI may contact as references.
Please provide reference information here.
Include: name, phone number, email, relationship, and length of relationship for each reference.
*
Powered by
EMF
Web Form
Report Abuse
