Volunteer Application - Alzheimer's Association Greater Indiana
You can learn more about our chapter and events by calling, emailing, or visiting our website.

Alzheimer’s Association Greater Indiana Chapter
50 E. 91st Street, Indianapolis, IN 46240
Ph: 317-575-9620, 24/7 Helpline: 800.272.3900
Email: indianavolunteer@alz.org
Web: www.alz.org/indiana
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To review VOLUNTEER DESCRIPTIONS before filling out this application, click here:
https://alz.org/indiana/documents/VolunteerSummaryIN_2017.pdf
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If you are under 18, please have your parent/guardian sign and date the below forms.
Contact Information
First Name *
Your answer
Last Name *
Your answer
Email (personal) *
Please provide personal email to be contacted about volunteering.
Your answer
Home/Cell Phone Number *
(xxx-xxx-xxxx)
Your answer
Home Street Address *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Association contact
If you've already been in contact with an Alzheimer's Association staff person, please enter their name (if known).
Your answer
Personal Information
Birthdate
(MM/DD/YY)
Your answer
Education/Degree
Your answer
Would you be willing to share your personal story or connection with Alzheimer's disease?
The purpose of this would potentially be for sharing on social media, newsletters, media stories or interviews, etc.
Employer
This is very helpful and used only to determine if company has a donation program for volunteer service hours. If you are aware of an employer donation program for volunteer service or a matching gift program, please include that note.
Your answer
Ethnicity
If provided, your answer will not be used to determine eligibility for volunteer service.
Special Skills
Volunteer Experience and/or Why
Please include any info about what motivates you to volunteer and/or any other volunteer experiences.
Your answer
Do you have a connection to someone who's had or has Alzheimer's disease? I am a: *
Required
Medical Concerns
If you have any medical conditions or restrictions that you'd like us to be aware of in case of emergency, please explain below.
Your answer
Emergency Contact Info *
Please provide NAME & PHONE Number of someone we can contact in case of emergency while you're volunteering with us.
Your answer
Volunteer Interests - Activities
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To review the volunteer summaries to best select your interests below, click the link below:
https://alz.org/indiana/documents/VolunteerSummaryIN_2017.pdf
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Please select at least one activity, and/or all that apply. We will contact you to discuss your interests and find a best fit for you!

** Position requires further training and/or commitment forms.
+ Position requires background check
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I am ONLY interested in volunteering one day at a fundraising event
Only select "yes" for a one time, one-day committment at an event. Select "no" if you want to be part of a Planning Committee or any of the positions below.
Development/Events Committees
Select one or more if interested in joining the planning committee. If you're only interested in helping on the one day of special events, please select that above.
Advocacy
Community, Programs, Education
Communications
Great for those who enjoy grassroots marketing (healthfairs, material drop-offs,etc), writing, and/or social media.
Other
Application Signatures
All potential and current volunteers are required to understand these policies and have their (electronic) signature on file.

I understand in order to become an Alzheimer’s Association volunteer, I may be required to complete further training to prepare me for my position. If you are under 18, please have your parent/guardian sign.

Please read the following and then sign below. This will help ensure a streamlined "paperwork" process should you become a volunteer.
Statement of Confidentiality
Conflict of Interest agreements
Code of Conduct.
General Liability Waiver
Statement of Confidentiality Agreement
Confidential information is defined as any information that a Chapter volunteer learns about Alzheimer’s Association Greater Indiana, or its members or donors, as a result of working for Alzheimer's Association that is not otherwise publicly available. Volunteers may not disclose confidential information to anyone who is not employed by Alzheimer's Association or to other persons employed by the Association who do not need to know such information to assist in rendering services. The disclosure, distribution, electronic transmission or copying of Alzheimer's Association confidential information is prohibited. Any volunteer who discloses confidential information will be subject to possible separation, even if he or she does not actually benefit from the disclosure of such information.
Conflict of Interest Agreement
I understand that my personal and business affairs must be conducted in such a manner as to avoid any conflict of interest with my duties and responsibilities as a volunteer. A conflict of interest may exist when a volunteer, a volunteer's family member, or any organization that a volunteer is affiliated with stands to gain benefit, either directly or indirectly, from the volunteer's involvement with the Chapter. Because of the public service mission of the Alzheimer’s Association, it is particularly important that the community have confidence in the management and administration of the organization. Each board member, employee, and volunteer of the Alzheimer’s Association shall exercise good faith and honesty in all dealings and transactions related to his/her duties to the Alzheimer’s Association.

I have read and am fully familiar with the organization’s Conflict of Interest Policy. I agree to disclose promptly, in accordance with the requirements of the Policy, any additional interests, which may arise after the filing of this statement.

Except for the matters listed below, there is no situation in which I am involved, in which my decision on behalf of the Alzheimer’s Association may be influenced by my own personal gain of advantage, financial or otherwise, or that of any immediate family member.
Signature - Conflict of Interest & Confidentiality *
By typing my name below, I acknowledge that it's equivalent to my signed signature as agreeing to the above. I understand the above policy and pledge not to disclose confidential information.
Your answer
Explanation of possible conflicts of interest
If you feel you may have a conflict of interest, please briefly explain below.
Your answer
Volunteer Code of Conduct
Should you become a volunteer for the Alzheimer's Association Greater Indiana Chapter, please read and sign the below Code of Conduct to ensure we maintain a safe and productive environment for our volunteers, employees, and constituents.

As a volunteer, I will:
- Represent the Chapter with professionalism and dignity
- Follow through and complete accepted tasks
- Follow through and complete processes/procedures pertaining to position
- Display respect and courtesy for employees, volunteers, and participants
- Offer my services without monetary compensation

As a volunteer, I will NOT:
- Use vulgar or inappropriate language while representing the Chapter
- Consume or be under the influence of alcohol or illegal drugs at Chapter offices or on official Chapter business. This includes medications prescribed by a physician that may affect your ability to safely perform your job or create an unsafe environment for others
- Abuse, misuse, steal or damage Chapter property or the property of co-workers
- Engage in acts of sexual harassment or harassment relating to age, race, disability, religion, or sexual orientation of a Chapter employee, volunteer, or participant
- Fight with, threaten or attempt bodily injury to a Chapter employee, volunteer, or participant
- Display excessive absenteeism or tardiness
- Speak on behalf of another company or organization while on assignment with the Chapter
General Liability Waiver
Please CLICK THE LINK BELOW to carefully review the General Liability Waiver. By typing my name below, I acknowledge that it's equivalent to my signed signature as accepting and understanding of the entire Volunteer Waiver & Release Form.
http://alz.org/indiana/documents/Waiver_Release_Form_AlzIN.pdf
Signature - Waiver & Code of Conduct *
By signing below, I accept and understand the entire Volunteer Waiver & Release Form. I have also read and agree to abide by the Alzheimer's Association Greater Indiana Chapter Code of Conduct. By typing my name below, I acknowledge that it's equivalent to my signed signature as accepting and agreeing to all above.
Your answer
How did you hear about our Volunteer Opportunities? *
Please help us learn how we're reaching volunteers by checking all that apply to you..
Required
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