* = answer required

*Date:

*Volunteer Name:

Address:

City:

State/Zip Code:

* Day Phone:

* Email:

Can we add you to our email list? Yes: No:

* Age: Under 18: 18-60 Over 60:

Career Experience:

Volunteer Experience:

Are You a Student? Yes: No:

* How did you learn about Meals on Wheels?

*I am interested in helping as: (Please check your choice)

Food Packer: 7:00 - 10:30 am

Driver: 10:30 am - 12:30 pm **

Typing/office: 7 am - 10:30 pm

Friendly Visitor: 10:30 am - 12:30 pm

Development Office: Computer input, filing, bulk mailing, etc. 10 am - 2 pm

* Many volunteers prefer to work on a regular schedule. When can you help? Please check day or days available

Monday

Tuesday

Wednesday

Thursday

Friday

* We need ON-CALL volunteers

May we call you to be a substitute?

Yes: No:

* Please check the days you are available to substitute. Note: Do not check your regular day(s) as an "On Call" day.

Monday

Tuesday

Wednesday

Thursday

Friday

* I prefer to work at the location chosen below

DOWNTOWN 241 Cedar Ave. (562) 432-6215

NORTH L.B. 1115 E.Market (562) 422-2118

NORTH EAST L.B. 5633 E. Wardlow (562) 420-9660

EAST L.B. 217 Termino (562) 433-0232

*In Case of Emergency, please notify:

* Name: * Phone:

* Relationship to You:

Address: City, State, Zip:

Driver Information: Insurance Company Name and Address of Insurance Agent

Insurance Company: Phone:

Address: City, State, Zip:

Insurance Policy No. :

Expiration Date: