Volunteer application new

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.