Form Center

2. Date:
4. First Name
5. Last Name
7. Date of Birth
8. Email
9. Best Phone Number
11. Address1
13. City
14. State
15. Zip
17. Preferred Pronouns
    -- Select One --She, her, hersHe, him, hisThey, them, theirs
18. Ethnicity
20. Past Volunteer Experience/ Organizational/Club Affiliations:
22. Check all that apply...

    1. Activity/Group Leader/ Coordinator
    2. Ambassador
    3. Board Member (Friends/Commission)
    4. Client Assistant (grocery shopper, etc...)
    5. Craft Group (Knitter/Quilter)
    6. Computer/i Pad/ Phone Tutor
    7. Data Entry
    8. Driver Escort (transporting people to medical appointments)
    9. Deep Cleaning
    10. Face of Fitchburg (reception)
23. You can make a difference!

    1. Food Pantry/Donation Support
    2. Foot Care Clinic Aide
    3. Gardener
    4. Host/Hostess
    5. Instructor: Exercise, Crafts, Dance, Lecture etc...
    6. Meal Driver- Home delivered meals
    7. Meal Program- Kitchen Staff
    8. Nurse Program
    9. Performer
    10. Photographer for Events
    11. Special Events (Pancake Breakfast, Fundraisers)
    12. Create your own volunteer experience: What would you like to offer?
25. Availablility
    -- Select One --All/ Any MorningsAll/ Any AfternoonsMonday MorningsMonday AfternoonsTuesday MorningsTuesday AfternoonsWednesday MorningsWednesday AfternoonsThursday MorningThursday AfternoonFriday MorningFriday Afternoon
27. Service Commitment

    1. Weekly Volunteering
    2. Every Other Week Volunteering
    3. Monthly Volunteering
    4. As needed/ PRN Volunteering
    5. Episodic Volunteering
29. 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
    8. Team Player
    9. Quick Learner
30. or...

    1. Independent
    2. Leadership/ Managment
    3. Excellent Follower
    4. Musical
    5. Tech Savvy
    6. Problem Solver
    7. Writing & Editing
    8. Flexible
    9. Creative/Out of the Box Thinker
32. Why do you want to Volunteer at the Fitchburg Senior Center?
34. Education:
    -- Select One --High SchoolSome College/Tech TrainingAssociates DegreeBA,BS DegreePh. D.MD
35. Degree or Specialty?
37. Ocupation/ Work Experiences
39. Do you fluently speak another language aside from English? Language(s) spoken? Can you translate this language?
41. List three adjectives to describe yourself:
42. Hobbies, Interests & Causes that are important to you:
44. 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
46. Is there anything physically/medically that may limit your commitment to volunteering?
    -- Select One --YesNo
48. If Yes, please elaborate:
50. Confidentiality & Liability 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. I also 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.

52. 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.
54. Signature of Parent/Guardian (if applicant is under 18 years of age)
56. Emergency Contact?
57. Phone Number
58. Relationship
Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

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