Form Center

2. 
3. Membership and Volunteer Application

   The Middleton Senior Center tracks participation in programs as well as volunteer hours.  Please complete this form and you will be given a key card to swipe each time you come into the Senior Center.  Thank you!

5. Name:*
6. Date:*
8. Address:*
10. Home phone:*
12. Cell Phone:*
14. Date of Birth*
16. Gender*
    -- Select One --MaleFemalePrefer not to say
17. Ethnic Status*
    -- Select One --African AmericanAsian AmericanCaucasianHispanicNative AmericanPrefer not to say
19. E-Mail*
21. Why do you want to Volunteer?*
23. Please list your availability (Specific Days, AM or PM shifts)
25. Please list any disabilities:
27. Do you live alone?
    -- Select One --YesNo
29. How did you hear about this opportunity?
31. Volunteer Opportunities

    Please select all that apply

    1. Receptionist/Front Desk
    2. Dining Center Assistant
    3. Home Delivered Meals Driver
    4. Special Events Volunteer (plan, implement, set up)
    5. RSVP Driver for Medical Appts
    6. Knitting/Sewing Projects
    7. Blood Pressure/Nurse Assistant
    8. Foot Care Clinic Assistant
    9. Newsletter Collating
    10. Travel (Day Trip) Planning
    11. Bakery Assistant (pick up donated bakery)
    12. Tax Counseling
    13. Tax Intake
    14. Group/Class Leader
    15. Decorating (seasonal)
    16. Data Entry
    17. Guest Musician
    18. Flower Gardens
    19. Mending Group
    20. Intergenerational
32. Training Skills

    Please select all that apply

    1. Arts/Crafts/Quilting
    2. Food Service/Meal Prep
    3. Performer
    4. Public Relations
    5. Other Language(s)
    6. Computer Experiance
    7. Health Services: RN/PT/OT/Aide
    8. Photography/Photoshop/Scrapbook
    9. Receptionist/Visitor Experiance
    10. Other Talents/Interests/Hobbies
33. Any Physical Limitations?

    Please select any that apply

    1. No Heavy Lifting
    2. Limited Hearing
    3. Limited Walking
    4. Low Vision
    5. Other Restrictions
35. References - Please list two references not related to you whom we may contact:
37. Reference #1
39. Reference Name
41. Reference Address
43. Reference Telephone
44. Reference Email:
46. Reference #2
48. Reference Name
50. Reference Address
52. Reference Telephone
53. Reference Email:
55. Emergency Contact Information:
57. Name
59. Address
61. Telephone
62. Relationship:
64. I would like to receive the monthly newsletter by mail.
    -- Select One --YesNo
66. Photo Release:*

    I grant to the Middleton Senior Center, the right to take photographs of me in connection with my volunteer assignments. I agree that the Middleton 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.

68. Confidentiality Statement:*

    All volunteers of the Middleton Senior Center shall maintain confidentiality in the handling and use of participant information and records.  Any information relating to individuals attending programs or activities at the Middleton Senior Center is not to be discussed at any time within or outside the Middleton Senior Center.  This information may include personal information about staff, participants or overall agency business.

Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit Submit and Print

* indicates a required field