Volunteer Application Form

Alzheimer
Outreach Services
of McCormick Home (AOS)

2022 Kains Road
London, Ontario
Canada N6K 0A8
Tel: (519) 439-9336
Fax: (519) 439-4960
www.alzheimeroutreach.org

Please fill out the form below and our
Volunteer Coordinator will contact you!

Enhance someone else's life while changing your
own, join the AOS team today!
First Name:
 Last Name:
Address:
City:
Province:

Postal Code:

Phone:
Email Address:
Birth Date:

 
Emergency Contact Name:
Emergency Contact Phone Number:
 

Please indicate the referral source which prompted you to contact McCormick Home:
Lawn Sign Acquaintance T.V. or Newspaper Other
Mode of Transportation:
Car City Transit Other
Present Occupational Status and Background:
Student Employed Full-Time Employed Part-Time Retired
 
Do you speak any languages other than English?
What community organizations do you belong to?
 
Personal Reference (former employer, neighbour, etc.):
Name:
 Address:
Phone:
  
What do you hope to achieve as a volunteer?
Would you sign a consent form for a London Police Department References Check?
 
Yes No
   
Do you have any previous volunteer experience?
   
Do you have any work experience, education or training with seniors?
   
Which days and times are you available to volunteer?
   
Are there any limitations or restrictions we should be aware of (i.e. health problems, transportation etc.)?
   
We have several areas where volunteers are utilized. Please select the ones that interest you:

Residential Programs
Monday-Sunday

Recreational Activities & Entertainment
Restorative Walking Program
Special Skill, Talent Program
Assist residents to/from medical appts
Mealtime Assistance
Assisting with Saturday Tea
Evening Walking Program
Hair Salon

Alzheimer Outreach Service
Monday-Friday (days only)

Recreational Activities
Special Skills
Afternoon Dances
Talent Program Assistant


 

ALZHEIMER OUTREACH SERVICES
Our Vision is to share in the future
while acknowledging the present and
respecting the past of those we serve.
 
Alzheimer Outreach Services | 2022 Kains Road | London, Ontario | 519-439-9336 | Privacy Policy