Volunteer Form

Please verify all fields in the form are correct before submission to ensure all information is correct.

GENERAL INFO

EMERGENCY CONTACT

EDUCATION

Select Highest Completed

PERSONAL INFO

HAVE YOU OR YOUR FAMILY HAD PERSONAL/PROFESSIONAL EXPERIENCE WITH:

PLEASE ANSWER THE FOLLOWING QUESTIONS AND GIVE DETAILS IF ANSWER IS YES:

PLEASE RESPOND TO THE FOLLOWING:

REFERENCES

Please provide COMPLETE contact information for three non-family references that have known you for at least one year.
Please do not list a relative or significant other. If possible, please list an employer or supervisor.

Reference #1

Reference #2

Reference #3

BACKGROUND CHECK

I hereby affirm that all of the answers provided on my volunteer application are true. I hereby authorize ADAKC, and any law enforcement agency they authorize, to investigate my background to determine my fitness as a potential volunteer.


I understand that the information requested in this application will be used only for the purpose of determining my suitability as an ADAKC volunteer. I am aware of the sensitive and confidential nature of the official documents, reports and other material I will examine in my capacity as a ADAKC volunteer. I will discuss these matters only with those persons directly involved in the program or who will be consulted for their professional knowledge and expertise.


I also understand that if for any reason it becomes apparent that my activities are contrary to the policies, goals and/or philosophy of the ADAKC program, and their desire to provide quality services to families affected by Alzheimer's Disease, Dementia and other related disorders, my services as a ADAKC volunteer will be terminated.


I submit the statements on this application are true, complete, and correct to the best of my knowledge. I understand that falsification on this application can disqualify me from consideration or can result in dismissal at a later time.

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