Survey - Mid-America 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.

1.

Preferred Contact Information:

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

*

Name:

First Required	Last Required

*

Email: Required

*

Street 1: Required

*

City/State/ZIP:

City Required	State Required	ZIP Required

Phone Number:

Employer:

Occupation:

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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2.

Question - Not Required - Group Volunteering With:

*3.

Question - Required - How do you prefer to be contacted about volunteer opportunities?

4.

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

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

5.

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

6.

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

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

Please indicate your potential interest in any of the following areas:

7.

Question - Not Required - Office Work

	Computer entry work
	Help with mailings
	Miscellaneous office work

8.

Question - Not Required - Education, Awareness & Advocacy/Public Policy

	Speakers Bureau
	Visiting local legislators
	Letter writing campaign

9.

Question - Not Required - Walk to Defeat ALS

	Sponsor the event
	Become a team captain
	Serve on the committee
	Volunteer at the event

10.

Question - Not Required - Joe McGuff ALS Golf Classic

	Purchase a team
	Serve on the committee
	Auction item procurement
	Volunteer at the event

11.

Question - Not Required - A Night of Hope Gala

	Purchase a table
	Serve on the committee
	Auction item procurement
	Volunteer at the event

12.

Question - Not Required - Other Events

	I am interested in helping out with other Chapter-hosted events
	I am interested in coordinating an event to benefit the Chapter

*13.

Question - Required - I hereby waive all claims against The ALS Association, sponsors or personnel for any injury that I may suffer from my participation in these events. I grant full permission for organizers to use photographs, videotapes, motion pictures, recordings or any other record of these events.