Survey - St. Louis Chapter Volunteer Form - The ALS Association Massachusetts Chapter

Are you interested in a volunteer opportunity?

Please complete this online interest 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:

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 Massachusetts Chapter.

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2.

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

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

3.

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

4.

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

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

5.

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

6.

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

7.

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

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

8.

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
	Transportation/deliver equipment to PALS

9.

How often are you interested in volunteering?

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

10.

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

	Monday
	Tuesday
	Wednesday
	Thursday
	Friday
	Saturday
	Sunday

11.

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

12.

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

Phone

Email

US Postal Service

13.

Question - Not Required - How did you hear about The ALS Association St. Louis Regional Chapter?

14.

Question - Not Required - If you selected other, please provide more details here: