Volunteer Profile Form

Volunteer Profile

Person details

Name *

First name

Last name

Preferred Name

Person or Household Address

Address line 1

Address line 2

Address line 3

Address line 4

Town/Suburb

City

Postcode/Zip

Email address

Home phone

Cell phone

Date of Birth *

Experience/Skills

Previous experience

Please include any work and/or past experience and skills that may be useful, including any experience you have with people with dementia.

Hobbies and interests

Hobbies & Interests #1

Hobbies & Interests #2

Hobbies & Interests #3

Hobbies & Interests #4

Hobbies & Interests #5

Volunteer roles

Please select as many as you wish.

Companion

Support a person with dementia in the temporary absence of a caregiver, to give both parties "time out".

Caring Caller

Combat loneliness for a person with dementia via regular phone calls. To provide conversation and socialisation they might otherwise not get.

Administration

Provide a variety of administration activities for the Society that do not usually involve direct contact with clients

Blokes Shed

Provide support for persons with dementia in a Blokes Shed role, assisting with carpentry, painting and the like.

Driver

Can be called on to drive the client or caregiver for routine or emergency appointments or activities.

Event Support

Provide support for Society events, such as Memory Walks or Fundraisers that do not usually involve direct contact with clients.

Availability

Please indicate the potential times/days/time frames you are available to volunteer.

Availability - time frame

Availability - days

Availability - Time

Preferred Region/s to Volunteer

East Coast

Edgecumbe

Kawerau

Manawahe

Matata

Murupara

Ōhope

Ōpōtiki

Whakatāne

Health issues

Do you have any health issues? If so, please state them here.

I have a current and clean driver's license.

I have, and am willing to use, my own vehicle.

In case of emergency

Emergency - Name (1)

Emergency - Contact # (1)

Emergency - Relationship (1)

Police check

We are required to request a Police check for all of our volunteers.

I agree to a Police check.

Confidentiality Statement, Alzheimer’s EBOP: Information provided on this form is for Alzheimer’s EBOP purposes only and will not be used for any other purpose without consent of the person completing the form.

Please check the highlighted fields

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