Form Center

2. 
3. Membership and Volunteer Application

   The Middleton Senior Center tracks participation in programs as well as volunteer hours.  Please complete this form if you would like to become a member.  If also interested in volunteering, please complete the volunteer section of this application.  Volunteer opportunities are only available between 8:00-4:00 Monday-Friday.

   --Please stop by the Center to pick-up your member keycard. It will be ready within 1 week of submitting your membership application--

5. Name:*
6. Date:*
8. Street Address:*
9. Apartment #:
11. City:*
12. State:*
13. Zip Code:*
15. Home phone:*
16. E-Mail*
18. Date of Birth*
19. Cell Phone:*
20. Gender*
    -- Select One --MaleFemalePrefer not to say
21. Ethnic Status*
    -- Select One --African AmericanAsian AmericanWhiteHispanicNative AmericanPrefer not to say
23. Disabilities:
25. Monthly Newsletter: 3 ways to receive our newsletter!

    1. Available on our website, www.cityofmiddleton.us/seniorcenter

    2. Sign up at www.cityofmiddleton.us/seniorcenter to have it emailed to you.

    3. Stop by the center and pick up a paper copy to take home. 

26. Photographic Release
    -- Select One --YESNO

    I hereby grant and convey unto the Municipality all right, title, and interest in any and all photographic images and video or audio recordings made by the Municipality during the undersigned’s Activities with the Municipality, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings  

28. Emergency Contact Information:
30. Name
31. Relationship:
32. Telephone
34. Volunteer Information: Interested in volunteering at our center?
35. Please list your availability (Specific Days, AM or PM shifts)
37. Why do you want to Volunteer?
39. Volunteer Opportunities

    Please select all that apply

    1. Receptionist/Front Desk
    2. Dining Center Assistant
    3. Home Delivered Meals Driver
    4. Special Events Volunteer (plan, implement, set up)
    5. RSVP Driver for Medical Appts
    6. Knitting/Sewing Projects
    7. Blood Pressure/Nurse Assistant
    8. Foot Care Clinic Assistant
    9. Newsletter Collating
    10. Travel (Day Trip) Planning
    11. Bakery Assistant (pick up donated bakery)
    12. Tax Counseling
    13. Tax Intake
    14. Group/Class Leader
    15. Decorating (seasonal)
    16. Data Entry
    17. Guest Musician
    18. Flower Gardens
    19. Mending Group
    20. Intergenerational
40. Training Skills

    Please select all that apply

    1. Arts/Crafts/Quilting
    2. Food Service/Meal Prep
    3. Performer
    4. Public Relations
    5. Other Language(s)
    6. Computer Experiance
    7. Health Services: RN/PT/OT/Aide
    8. Photography/Photoshop/Scrapbook
    9. Receptionist/Visitor Experiance
    10. Other Talents/Interests/Hobbies
41. Any Physical Limitations?

    Please select any that apply

    1. No Heavy Lifting
    2. Limited Hearing
    3. Limited Walking
    4. Low Vision
    5. Other Restrictions
43. References - Please list two references not related to you whom we may contact:
45. Reference #1
47. Reference Name
49. Reference Address
51. Reference Telephone
52. Reference Email:
54. Reference #2
56. Reference Name
58. Reference Address
60. Reference Telephone
61. Reference Email:
63. Address
65. Confidentiality Statement:*

    All volunteers of the Middleton Senior Center shall maintain confidentiality in the handling and use of participant information and records.  Any information relating to individuals attending programs or activities at the Middleton Senior Center is not to be discussed at any time within or outside the Middleton Senior Center.  This information may include personal information about staff, participants or overall agency business.

    --Please stop by the Center to pick-up your member keycard. It will be ready within 1 week of submitting your membership application--

Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit Submit and Print

* indicates a required field