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* Date Format: 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 MonthlyAgeWhat age range are you?*17 years & younger18 years & olderCriminal HistoryHave you ever been convicted of a criminal offense?*NoYesIf Yes, please explain:*Are you in need of community service/court mandated hours?*NoYesIf Yes, please tell us more:*Prior AssistanceHave you received assistance from WVS in the past six months?*YesNoIf yes, please explain:*Special AccommodationsDo you have health restrictions or require special accommodations?*YesNoIf yes, please explain:*PreferencesAssignment Preference*Check all that apply. Clothes Shop Food Shelf Home Delivered Meals Food RescueAre 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 AgreeStep 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:*December 13th 2018 at 10:00AM in the Chestnut RoomJanuary 10th at 10:00AM in the Chestnut RoomFebruary 14th at 10:00AM in the Chestnut RoomMarch 14th at 10:00AM in the Chestnut RoomApril 11th at 10:00AM in the Chestnut RoomMay 9th at 10:00AM in the Chestnut RoomJune 13th at 10:00AM in the Chestnut RoomJuly 11th at 10:00AM in the Chestnut RoomAugust 8th at 10:00AM in the Chestnut RoomSeptember 12th at 10:00AM in the Chestnut RoomOctober 10th at 10:00AM in the Chestnut RoomNovember 14th at 10:00AM in the Chestnut RoomDecember 12th at 10:00AM in the Chestnut Room