Volunteer application

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.