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. Volunteer Position Intrests:

    1. Activity Leader/ Coordinator
    2. Advisory or Commission on Aging Well Board Member
    3. Craft Group (Knitter/ Quilter)
    4. Data Entry
    5. Deep Kitchen Cleaning
    6. Donations Support
    7. Driver Escort
    8. Fitchburg Singer
24. Check all that apply...

    1. Food Pantry/Food Box Delivery
    2. Foot Care Clinic Aide
    3. Gardener
    4. Greeting Card Instructor
    5. Grocery Shopper (Online ordering)
    6. Home Chores
    7. Instructor (Exercise, Dance & Other)
    8. Meals on Wheels Driver
25. You can make a difference!

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

    1. Weekly Volunteering
    2. Every Other Week Volunteering
    3. Monthly Volunteering
    4. As needed/ PRN Volunteering
    5. Episodic Volunteering
31. Skills

    1. Advocacy
    2. Spanish Speaking/ Translator
    3. Health Care- Retired Nurse/ Physician
    4. Teacher
    5. Support Group Leader
    6. Leadership/ Managment
32. Talents

    1. Organizing
    2. Creative/ Out of the box thinker
    3. Musical
    4. Tech Savvy
    5. Problem Solver
    6. Handywo/man
33. Abilities

    1. Building Relationships
    2. Team Player
    3. Excellent Follower
    4. Quick Learner
    5. Independent
    6. Flexible
    7. Problem Solver
35. Why do you want to Volunteer at the Fitchburg Senior Center?
37. Education:
    -- Select One --High SchoolSome College/Tech TrainingAssociates DegreeBA,BS DegreePh. D.MD
38. Degree or Specialty?
40. Ocupation/ Work Experiences
42. Volunteer Experiences/ Organizational/ Club Affiliations:
44. List three adjectives to describe yourself:
45. Hobbies, Interests & Causes that are important to you::
47. 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
49. Is there anything physically/medically that may limit your commitment to volunteering?
    -- Select One --YesNo
51. If Yes, please elaborate:
53. 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.
55. 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.
57. 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.
59. Signature of Parent/Guardian (if applicant is under 18 years of age)
61. Emergency Contact?
62. Phone Number
63. Relationship
Leave This Blank:


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

    This field is not part of the form submission.

67. Submit

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