EmailMe Form - Northeast MA Walk to End Alzheimer’s Volunteer

Name *
First Last
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Birth Date *
MM / DD / YYYY
Phone *
### - ### - ####
Business Phone
### - ### - ####
Cell Phone
### - ### - ####
Email *
Company Name
Job Title
Emergency Contact Name *
First Last
Emergency Contact Phone *
### - ### - ####
Emergency Contact Relationship *
Gender
Male
Female
Rather not say
How did you hear about the 2012 Walk to End Alzheimer’s? *
Television Advertisement
Radio Advertisement
Print Advertisement
Web Advertisement
Other Advertisement
I saw a poster or brochure in my community
I was recruited at a community event
I received information in the mall
E-mail from the Alzheimer’s Association
Phone call from the Alzheimer’s Association
Alzheimer’s Association Website
Facebook
Twitter
Family
Friend
Coworker
My company
I have volunteered in the past
Other
How many years have you participated in the Walk? *
What is your first choice as a volunteer position? *
Set up (approx 6-9am)
Greeter (approx 7:30-10am)
Registration (approx 8-10am)
Promise Garden (approx 8-10am)
Food (approx 10am-12:30pm)
Route cheerleader/water stop (approx 9:30am-noon)
Green Team (approx 10am-12:30pm)
Advocacy recruitment (8-10am, 11-12:30pm)
Children's Activities (approx 8am-10am and 11am-12:30pm)
Breakdown (approx 11:30am-1:30pm)
What is your second choice as a volunteer position? *
Set up (approx 6-9am)
Greeter (approx 7:30-10am)
Registration (approx 8-10am)
Promise Garden (approx 8-10am)
Food (approx 10am-12:30pm)
Route cheerleader/water stop (approx 9:30am-noon)
Green Team (approx 10am-12:30pm)
Advocacy recruitment (8-10am, 11-12:30pm)
Children's Activities (approx 8am-10am and 11am-12:30pm)
Breakdown (approx 11:30am-1:30pm)
Comments
I am interested in more information about (check all that apply):
Promoting the Walk to End Alzheimer’s in my community.
Approaching my employer to form a Walk to End Alzheimer’s team.
Approaching my employer as a Walk to End Alzheimer’s sponsor.
Sharing my personal story with my local newspaper. Please contact me.
Joining the Walk to End Alzheimer’s steering committee.
Signing up as an advocate in the fight against Alzheimer’s disease.
Including the Alzheimer’s Association in my will, trust, or estate plan.
More Information about Alzheimer’s disease.
Additional volunteer opportunities with the Alzheimer’s Association.
Please choose the closest affiliation you have to the cause? *
Agreement
I agree

I hereby waive all claims against the Alzheimer's Association, sponsors, or any personnel from any and all claims that may arise from or result in any expenses, personal injury, loss or damage incurred to me or by me during my volunteer participation in this event. I also grant full permission for organizers to use photographs, films or videos of me and quotes from me in legitimate accounts and promotions of this event.