Date
Last Name
First Name
Maiden or Other Name
Address
City     AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY State     Zip Code
Home Telephone Number
Work Phone Number
Cell Phone Number
Best Time to Reach You?
Which Phone?     Home     Work     Cell
Email Address   (not disclosed to other sources)
Month, Day, and Year of Birth
Are you over 18?     Yes     No   (if not, a signature from a parent/guardian will be needed)
Do You Have Your Own Transportation?     Yes     No
(NOTE: Currently, NO Bus Service exists to the Distribution Center)

Ethnicity (please check one)
White-Caucasian
Black-African American
Latino-Hispanic
Native American
Asian-Pacific Islander
Multi-Racial
Southeast Asian
Other    

Place of Employment/Position
(check with Human Resources to see if your workplace has a "corporate match" program, such as Corporate donations for volunteer hours or matched donations)

Availability (Please indicate all times and hours that you are available, and check times that you would prefer)

While most of our volunteer opportunities occur during the day between 9am-4:30pm, we do have some short term evening opportunities on occasion.

If applicable, please also see program descriptions below for hours of program where you would prefer to volunteer.

Monday:         morning     afternoon     evening
Hours available between 9am-4:30pm:
Tuesday:         morning     afternoon     evening
Hours available between 9am-4:30pm:
Wednesday:   morning     afternoon     evening
Hours available between 9am-4:30pm:
Thursday:       morning     afternoon     evening
Hours available between 9am-4:30pm:
Friday:           morning     afternoon     evening
Hours available between 9am-4:30pm:
Saturday:       morning     afternoon     evening
Hours available between 9am-4:30pm:

I would prefer to volunteer (check all that apply):
weekly   every other week   monthly

Work and Volunteer Related Experience/Skills:


Are You Fluent in (check all that apply):
Spanish   Russian   French    Other

Other Hobbies/Interests:


Any Physical Limitations? (please describe):


Can You Lift 40 lbs?     Yes     No

Are You Able to Stand for 2 Hours?     Yes     No


The following is a list of our program areas. Please rate your interest (1-highest) or just indicate if you would like to speak to someone further about the program. Please be aware that most programs require a volunteer to be 15 years of age or older to work without a guardian. Some positions require ages 18 and older. Also, most activities occur during the day with the exception of some special projects.

No Interest 1 2 3 4 5 6 7 8 9 10 11 12 More Info	Clothing Closet - Shifts: Monday-Thursday, 10am-Noon OR Noon-2pm and Friday-Saturday, 9am-Noon.
No Interest 1 2 3 4 5 6 7 8 9 10 11 12 More Info	Data Entry - Enter data into our database. Hours are flexible, but the day and time must be consistent.
No Interest 1 2 3 4 5 6 7 8 9 10 11 12 More Info	Distribution Center Reception - Shifts: Monday-Thursday, 10am-Noon OR Noon-2pm and Friday-Saturday, 9am-Noon.
No Interest 1 2 3 4 5 6 7 8 9 10 11 12 More Info	Food Pantry - Shifts: Monday-Thursday, 10am-Noon OR Noon-2pm and Friday-Saturday, 9am-Noon.
No Interest 1 2 3 4 5 6 7 8 9 10 11 12 More Info	Food Pantry Inventory Support - Shifts: Monday-Thursday, 10am-Noon OR Noon-2pm and Friday-Saturday, 9am-Noon.
No Interest 1 2 3 4 5 6 7 8 9 10 11 12 More Info	Food "Rescue" Drivers - Must have own transportation. Hours are determined in conjunction with Food Pantry Manager.
No Interest 1 2 3 4 5 6 7 8 9 10 11 12 More Info	Interpreter - MOM has intermittent need for volunteers who can interpret and translate for us. Times are flexible.
No Interest 1 2 3 4 5 6 7 8 9 10 11 12 More Info	Main Office Front Desk Reception - Answer phones, greet clients, and assist staff with office projects at MOM's Hubbard Avenue office. Shifts: Monday-Friday, 9am-Noon OR Noon-4:30pm.
No Interest 1 2 3 4 5 6 7 8 9 10 11 12 More Info	On-Call Substitute - We get many requests for volunteer needs at the last minute AND we need subs for our regular sites. Check here if you are willing to be on the "On-Call" list for MOM!
No Interest 1 2 3 4 5 6 7 8 9 10 11 12 More Info	One Time Project Support - MOM has various "seasonal" one-time only projects (such as School Supplies Drive) where volunteers are needed. These would mostly be daytime hours, but some evenings are available.
No Interest 1 2 3 4 5 6 7 8 9 10 11 12 More Info	Project for Older People (P.O.P.) - Hours are flexible. Check which you would like to help with: Give Rides Do Home Chores Shopping Friendly Visitor Respite Caregiver
No Interest 1 2 3 4 5 6 7 8 9 10 11 12 More Info	Stephen Ministry - This is a Christian mentoring program requiring 50 hours of training offered every two years in the fall. If you are interested, we will refer you to Dietrich Gruen for further information.

Donations: We are always accepting donations of food (call for our highest needs), gently used clothing (especially larger sizes), and other small appliances and housewares that could make a new apartment home. During late summer, we have an annual School Supplies Drive, and during Christmastime, a Sharing Christmas Program. Please call or email us if you have questions regarding these programs.


How did you hear about MOM and our volunteer opportunities? (check all that apply)

MOM's Web Site
United Way of Dane County Referred
Church is Part of MOM:
      Church Name
I Have Been a MOM Client:
      Approximate Dates Active as Client
Other:
      Explain


We appreciate you taking the time to fill out this Volunteer Application. You will receive a telephone call once your application has been processed. Thank you for your interest in MOM, and please email or call Carole Klopp, Director of Volunteer Services, at 826-3409 with any further questions.

BACKGROUND CHECK PERMISSION AND CONFIDENTIALITY AGREEMENT

By filling out this application and clicking "Submit" below, you are giving permission for a background check and agreeing to the following:

As a volunteer for Middleton Outreach Ministry, I agree: to promote its basic mission; to abide by the MOM Code of Conduct for Volunteers (separate document) and to keep CONFIDENTIAL all information I see, hear or read at MOM. I also give my consent to Middleton Outreach Ministry for staff to perform a background check for the purpose of securing my eligibility to serve as a Volunteer to MOM/POP clients. I understand that all information will remain confidential, that only MOM staff will have access to it, and that it will only be used as it pertains to my volunteer relationship with MOM.