If you would like to volunteer for any of these ALS Society of Quebec programs, you can register directly online (see below) or by simply printing and filling out the following downloadable application form and mailing it to us.

Volunteer Application

GENERAL INFORMATION
* Name :
* First name :
* Address :
Apt./Unit No :
* City :
* Province :
* Postal Code :
* Home telephone :
Telephone (work) :
E-mail :
Cell phone :
Emergency contact
Name :
First name :
Telephone :
Date of birth :
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912
Languages spoken :
French English Other
PROFIL
1. Have you ever worked as volunteer or been involved in volunteerism? :
Yes No
Please indicate : A- Where B- When C- In what capacity (position or role)
2. How did you find out about the Society's volunteer program? (Check all items that apply)
Call/office visit Volunteer action center Friend/Family The Internet Another volunteer Other:
3. Why do you want to work as a volunteer?
4. When are you available?
5. Are you currently employed? :
Yes No
Position and employer Employer's address
Can you provide us with an electronic version of your CV? :
Yes No
Please describe your work experience :
6. Are you prepared to apply for a criminal record check? :
Yes No
Note: Your final selection as a volunteer will depend on you passing a criminal record check. Should the check raise questions about your role as a volunteer or conflicts with your written or oral submissions, the Society reserves the right to refuse or cancel your commitment.
REFERENCES 1. Current or past employer / firm; 2. Educational institution; 3. Someone you know who practises a recognized profession, such as a physician or lawyer.
Name :
Address :
Relation to candidate: :
Phone number :
Name :
Address :
Relation to candidate: :
Phone number :
AUTHORIZATION
I attest that the information provided in this form is accurate and complete. I agree to act in conformity with the Society's rules and code. I authorize the ALS Society of Quebec to communicate with the individuals listed above as references and, if necessary, to perform a criminal record check.
COMMENTS(For office use only)