Volunteer Interest Form Contact InformationName* First Middle Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM slash DD slash YYYY Primary Phone*Email Address* InterestReferral Source*ChooseVolunteer Orientation AdFlyerA Friend or Family MemberMy EmployerMy SchoolThe ALS Association's StaffThe ALS Association's NewsletterThe ALS Association's WebsiteVolunteerMatchCraigslistLive Well WinonaAnother Internet Recruitment SiteOtherWhy are you interested in volunteering? Please list any previous experience, reasons for wanting to volunteer and/or what you hope to gain while volunteering.*AvailabilityWhen are you generally available to volunteer? FrequencyHow frequently would you like to volunteer?* One Time Weekly Every Other Week Monthly AgeWhat age range are you?* 17 years & younger 18 years & older Criminal HistoryHave you ever been convicted of a criminal offense?* No Yes If Yes, please explain:*Are you in need of community service/court mandated hours?* No Yes If Yes, please tell us more:*Prior AssistanceHave you received assistance from WVS in the past six months?* Yes No If yes, please explain:*Special AccommodationsDo you have health restrictions or require special accommodations?* Yes No If yes, please explain:*Preferences Assignment Preference*Check all that apply. Clothes Shop Food Shelf Home Delivered Meals Food Rescue Are there other ways you can help?*Emergency ContactIn the event of an emergency, whom should we contact?Name* First Last Home Phone Number*Work Phone Number*Cell Phone Number*Email Address* Relationship*ChooseAuntBoyfriendBrotherCousinCo-workerDaughterFatherFianceFianceeFriendGirlfriendGrandmotherHusbandMomMotherNeighborParentPartnerSelfSisterSonSpouseSupervisorWifeReferencesPlease provide two professional references we can contact about your application to volunteer. References will not be contacted until after your interview.1. Name* First Last Phone Number*Alternate Phone NumberEmail Address 2. Name* First Last Phone Number*Alternate Phone NumberEmail Address Please explain how you know each of the references you listed*I understand that this interest form does not automatically register me as a volunteer. I may need to complete a criminal background check (if 18 years of age or older) in determining my qualifications for volunteering. The information I provided on this application is accurate and current. I authorize WVS to verify this information and contact the references I listed as part of the volunteer screening process.*I understand that this interest form does not automatically register me as a volunteer. I may need to complete a criminal background check (if 18 years of age or older) in determining my qualifications for volunteering. The information I provided on this application is accurate and current. I authorize WVS to verify this information and contact the references I listed as part of the volunteer screening process. I Agree Step 3Attending a volunteer orientation is required prior to actively volunteering. Select an orientation date below. All orientations are held in the Chestnut Room at Winona Volunteer Services 402 East Second Street, Winona, MN 55987. Please select an orientation date below:* January 12th at 1:00PM in the Chestnut Room February 9th at 1:00PM in the Chestnut Room March 9th at 1:00PM in the Chestnut Room April 13th at 1:00PM in the Chestnut Room May 11th at 1:00PM in the Chestnut Room June 8th at 1:00PM in the Chestnut Room July 13th at 1:00PM in the Chestnut Room August 10th at 1:00PM in the Chestnut Room September 14th at 1:00PM in the Chestnut Room October 12th at 1:00PM in the Chestnut Room November 9th at 1:00PM in the Chestnut Room December 14th at 1:00PM in the Chestnut Room