CITY:

STATE:

ZIP:

HOME TELEPHONE:

EMPLOYER NAME:

EMAIL ADDRESS:

EMERGENCY CONTACT PERSON:

BIRTHDATE:

OCCUPATION:

HOBBIES:

Do you know someone affected by ALS

Why do you want to volunteer for ALSA of GA?

Have you volunteered for ALSA of GA before

Yes

No

If yes, in what capacity?

Please check the following volunteer activities and programs you would be interested in assisting with:

Planning Special Events
Advocacy
Speakers Bureau
Respite Care Provider
Marketing and Promotions
ALS Awareness Month
Support Group Meetings
Equipment Delivery

Please indicate any special skills, talents or interests:

Writing
Counseling
Graphic Arts
Training
Photography 
Educator              
Fundraising          
Meeting planner
Marketing/PR     
Public Speaking    
Accounting          
Website Development

Would you be in interested in a volunteer leadership position by serving on a committee for one of our fundraising special events? 

Yes
No

What is your volunteer availability:  Daytime     Evening          Weekends

Yes
No

Do you have computer/data entry skills?

Yes
No

If yes, what programs have you worked with?:

Do you have graphic design skills?

Yes
No

Would you be interested in staffing an ALSA of GA booth at a health fair or special education program? 

Yes
No

Would you be interested in receiving semi-monthly emails about what is happening at your local office including volunteer activities?  

Yes
No