Volunteer Online Form ... or, call 320-214-77140 ext 1180, to have a form mailed to you.

Name: Include First, middle and last name...  

Address:  

Home phone:

Cell phone:

Work phone:

Town: MN (Zip): Male:    Female:

E-mail address:

Today’s date: Age:     Date of Birth:    

Present Employer (if employed) Phone:

Job title Location:

Former occupation(s), if retired:

Students: List year, school, major, etc.

Person to notify in case of emergency:

Name      Day-Time Phone

Address Relationship

Other emergency information:

ADDITIONAL INFORMATION:

Which of the following volunteer activities interest you?

Friendly Visiting                                         Respite Care
Companion on Outings                              Shopping Assistance
Transportation                                          Household Projects
Grocery Shopping                                      Laundry/Ironing
Raking leaves/Yard work etc.                      Snow Removal
Home repairs                                             Window washing
Sewing/mending                                         Light housekeeping 
Fundraising assistance
(In  Other  below, add any of these items that interest you...

Clothing shopping; assist with Food Shelf food pick-up/delivery; Green Lake/"Let's Go Fishing... transportation

and/or accompany someone fishing or on boating trip; provide rides to Sunday PM community free meals; 

packing/unpacking or moving someone; sewing or mending; doing laundry and/or ironing; cooking a meal; 

assistance with vegetable or flower gardening, etc.

Other (describe):

What days and times are you available to volunteer?

Mon Tues Wed Thurs Fri Sat Sun   

Do you have any physical limitations or health problems which will require considerations or special assignments? Could you lift a wheel chair? Yes No

Please list any special skills, hobbies, and interests that could help in matching you with clients:                                                                                                     
Do you presently serve as a volunteer?  If so, please give name of organization, activity, and schedule.

What previous experience/training do you have with senior citizens?

If you will provide transportation, please complete the following:

Driver’s License: Number & State; add expiration date   

Automobile Insurance Company  

Automobile Insurance Policy Number

How did you find out about our volunteer program?

Brochure   Poster    Newspaper    United Way of West Central MN website
Program-where?: Other:

Please list references:

Name Relationship

Address Day-Time Phone

Name Relationship    
        
Address Day-Time Phone

Important:  I give permission for the Willmar Community Senior Network, LAHN to check the references listed above, and to do a background check. If you agree check here.  

Optional:  Other information you care to add?… such as other languages, ability to read or write Braille (grade 1 or grade 2), or American Sign Language, etc.  Phone or e-mail the office with any such optional information that  you wish to add.