Form Center

2. Date:
4. First Name
5. Last Name
7. Date of Birth
9. Address1
11. City
12. State
13. Zip
15. Email
16. Phone (home)
17. Phone (cell)
19. Preferred Pronouns
    -- Select One --She, her, hersHe, him, hisThey, them, theirs
21. Past Volunteer Experience/ Organizational/Club Affiliations:
23. Check all that apply...

    1. Food Pantry/Food Box Delivery
    2. Activity Leader/ Coordinator
    3. Craft Group (Quilting/Knitting/Art)
    4. Craft Instructor
    5. Computer/i Pad/ Smart Phone Tutor
    6. Data Entry
    7. Donations Support
    8. Driver Escort
    9. Fitchburg Singer
    10. Foot Care Clinic Aide
    11. Gardener
    12. Grocery Shopper (Online ordering)
    13. Home Chores
    14. Instructor (Exercise, Dance & Lecture)
    15. Meals on Wheels Driver
24. You can make a difference!

    1. Meals on Wheels- Kitchen Staff
    2. Newsletter (Assembly & Distribution)
    3. Performer
    4. Personal Client Assistant
    5. Photographer for Center Events
    6. Volunteer Nurse Program
    7. Special Events (Pancake Breakfast, Fundraisers)
    8. Create your own volunteer experience: What would you like to offer?
26. Availablility
    -- Select One --All/ Any MorningsAll/ Any AfternoonsMonday MorningsMonday AfternoonsTuesday MorningsTuesday AfternoonsWednesday MorningsWednesday AfternoonsThursday MorningThursday AfternoonFriday MorningFriday Afternoon
28. Service Commitment

    1. Weekly Volunteering
    2. Every Other Week Volunteering
    3. Monthly Volunteering
    4. As needed/ PRN Volunteering
    5. Episodic Volunteering
30. Skills, Talents & Ability:

    1. Advocacy
    2. Health Care- Retired Nurse/Physician
    3. Organizing
    4. Teacher
    5. Support Group Leader
    6. Handywo/man
    7. Building Relationships & Fundraising
31. or...

    1. Team Player
    2. Quick Learner
    3. Independent
    4. Leadership/ Managment
    5. Excellent Follower
    6. Musical
    7. Tech Savvy
    8. Problem Solver
    9. Writing & Editing
    10. Flexible
    11. Creative/Out of the Box Thinker
32. or...

    1. Building Relationships
    2. Team Player
    3. Excellent Follower
    4. Quick Learner
    5. Independent
    6. Flexible
    7. Problem Solver
34. Why do you want to Volunteer at the Fitchburg Senior Center?
36. Education:
    -- Select One --High SchoolSome College/Tech TrainingAssociates DegreeBA,BS DegreePh. D.MD
37. Degree or Specialty?
39. Ocupation/ Work Experiences
41. Do you fluently speak another langguage? Language(s) spoken aside from English? Can you translate this language?
43. List three adjectives to describe yourself:
44. Hobbies, Interests & Causes that are important to you::
46. How did you hear about our Volunteer Program?

    1. Friend
    2. Senior Center Web Page
    3. Social Media/ Facebook
    4. FACTv
    5. Nextdoor Fitchburg
    6. Fitchburg Star
48. Is there anything physically/medically that may limit your commitment to volunteering?
    -- Select One --YesNo
50. If Yes, please elaborate:
52. Confidentiality Statement:
    As a volunteer at the Fitchburg Senior Center, I understand that all information made available to me in the course of my work as a volunteer regarding the personal matters of clients and participants is confidential, and I will treat it as such.
54. Photo Release:
    I grant to the Fitchburg Senior Center, the right to take photographs of me in connection with my volunteer assignments. I agree that the Fitchburg Senior Center may use such photographs of me with or without my first name and for any lawful purpose, including such purposes as publicity, illustration, advertising, and Web content.
56. Liability Waiver:
    As a volunteer of the Fitchburg Senior Center I understand that I will not be considered an employee, agent or independent contractor employed by the City of Fitchburg for any purpose. I acknowledge and will neither accept nor claim entitlement to any salary or benefits of employment, including but not limited to insurance, retirement benefits, worker's compensation, travel expenses, or any other form of compensation of any kind.
58. Signature of Parent/Guardian (if applicant is under 18 years of age)
60. Emergency Contact?
61. Phone Number
62. Relationship
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

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