Survey - Connecticut Chapter Volunteer Form - The ALS Association Indiana Chapter

Are you interested in a volunteer opportunity?

Please complete this online interst form and we will contact you shortly.

Preferred Contact Information:

If you have previously registered, please to prepopulate your information.

*

Name:

First Required	Last Required

*

Email: Required

Street 1:

City/State/ZIP:

City	State	ZIP

Phone Number:

Employer:

Occupation:

Gender:

If you respond and have not already registered, you will receive periodic updates and communications from The ALS Association Indiana Chapter.

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Question - Not Required - Areas of specialized training, skills, talents (i.e. carpentry, photography)?

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Do you speak a foreign language?

Question - Not Required - If yes, please list them below:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Have you had experience working with someone with ALS?

Question - Not Required - Indicate which areas interest you:

	Administrative/clerical work
	Computer-data entry/word processing
	Fundraising/special events
	Media relations (write press releases, media contacts, etc.)
	Other
	Staffing health fairs (daytime hours needed)
	Photography (newsletter, events, Walk to Defeat ALS, etc.)
	Speaker's bureau
	Grant writing

Question - Not Required - If you indicated other, please describe your interest below:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Opportunities to volunteer with PALS (Person with ALS):

	Phone PALS
	PALS assistant at a special event
	Errands, chores, assist with paperwork, correspondence
	PALS home companion
	Meal preparation/delivery
	Transportation/deliver equipment to PALS

How often are you interested in volunteering?

(Select one of the available choices or enter a different value.)
Question - Not Required -

Question - Not Required - Choose your preferred day(s):

	Monday
	Tuesday
	Wednesday
	Thursday
	Friday
	Saturday
	Sunday

Question - Not Required - Please indicate time of day that is most convenient for you:

Question - Not Required - What is your preferred method of contact?

Phone

Email

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