Application Date: _______________
VOLUNTEER APPLICATION Stoughton Area Senior Center First Name: ______________ Middle Initial: ___ Last Name: _____________ Date of Birth: ___/___/___ Address: _________________________________________________________________________________ Township: ______________ Employment Status:
Phone #: __________________
Retired
Part-Time
Email: __________________________
Full-Time
Student
Describe your past work experience: ________ _________________________________________________ Clubs or organizational affiliations: __________________________________________________________ Previous volunteer experience: ______________________________________________________________
BACKGROUND SKILLS, TALENTS or TRAINING (Please check all that apply) Advocacy
Food Service/Meal Prep
Foreign Language:___________
Fundraising
Gardening
Grant Writing
Graphic Design
Health Service: ____________
Instructor of: _______________
Leadership/Supervision
Literature/Poetry
Maintenance
Marketing
Office Skills
Organization
Performer:dance/theatre/music
Program/Event Planning
Public Relations
Public Speaking
Reception
Sales/Purchasing
Writing/Editing
Other: __________________________________________________
AREAS YOU WOULD LIKE TO VOLUNTEER AT THE SENIOR CENTER: Birthday Card Manager
Blood Pressure Screening Attendant
Committee Volunteer
Computer Lab Attendant
Facebook Coordinator
Friendly Visitor
Gardener
Grant Writer
Instructor/Activity Leader
Laundry Assistant
Loan Closet Cleaner
Loan Closet Maintenance
Meals on Wheels Delivery
Meal Site Assistance
Newsletter Distributor
Newsletter Proofreader
Photo Display Artist
Photographer
Receptionist
RSVP Driver
Support Group Facilitator
Table Setting Assistant
Trip Escort
Welcome Buddy
Other: _________________________________________________ Intergenerational Programs: __ Classroom Helper
__ Class Speaker
__ Games/Skill-sharing
CURRENT AVAILABLITY: Weekdays
Weekends
Flexible
Specific Days: _______________
Best time of day: Mornings
Afternoons
Or Specific Times ___________________
Expected Level of Service: Weekly
Monthly
Occasional
Are you meeting a requirement for service hours?
Yes
No
If yes, how many hours ______________, and by what date: _______________________ What are the service hours required for? _______________________________________
PHYSICAL/MEDICAL LIMITATIONS: (i.e. no heavy lifting, limited walking, other health restrictions) Please explain. ________________________________________________________________________________________
IN CASE OF EMERGENCY NOTIFY: Name: ___________________________ Relation: ___________ Phone #:___________ Address: __________________________________________________________________
PERSONAL OR WORK REFERENCES: Please list two people, other than relatives. 1. Name: ___________________________
Relation: _________________ Phone #:___________
2. Name: ___________________________
Relation: _________________ Phone #:___________
Please return this form to: Stoughton Area Senior Center Attn: Volunteer Program 248 W. Main Street Stoughton, WI 53589 Email: cmcglynn@ci.stoughton.wi.us Staff will contact you once your completed application is returned.