Ice Bucket Challenge Progress

 

Visiting Volunteers Assistance Request

1. Information for Person Living with ALS

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Name:

 

 

 

     

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City/State/ZIP:

 

    

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What's this?

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*6.
Question - Required - What would you like a volunteer to assist you with?
Please make at least 1 selection from the choices below.

7.

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

*8.
Question - Required - What are your preferred day(s)? (The more flexibility you have, the greater chance of finding a volunteer whose schedule matches yours.)
Please make at least 1 selection from the choices below.

*9.
Question - Required - What time of day would be best for you to have a volunteer?




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11.

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

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*14.
Question - Required - Do you have any pets?
Please make at least 1 selection from the choices below.

15.

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

 

When this request is submitted, you will receive the form, Agreement to Receive a Volunteer, which must be signed and returned prior to initiation of the search for a volunteer.

   Please leave this field empty