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 Assistant
Newsletter Distributor
Bulletin Board/Photo Display
Newsletter Proofreader
Committee Volunteer
Photographer
Facebook Coordinator
Receptionist
Friendly Visitor
RSVP Driver
Gardener
Support Group Facilitator
Instructor/Activity Leader
Trip Escort
Intergenerational Programs
Welcome Buddy
Loan Closet Cleaner
Other: _________________________________________________
Meals on Wheels Delivery Meal Site Assistance
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: tnicoll@ci.stoughton.wi.us Staff will contact you once your completed application is returned.