Family Application for It Takes a Village
Please fill out the form below. Some of these questions are required by our funders; the demographic information you provide will be shared anonymously and your name and personal information will be kept private and confidential. If you have any questions please let us know. Thank you!

Lisa Dana Goding, Programs Manager
413-650-3640
Lisa@HilltownVillage.org
Who qualifies for a Home-Visit Volunteer?
We are delighted to match you with a home-visit volunteer if you can check *BOTH* boxes below: *
Required
Contact Information
Name of person filling out this form *
Your answer
Name(s) of partner(s) or other adults living in the home
Your answer
Baby's name (if no name yet, please put "TBD") *
Your answer
Baby's Birthdate or Estimated Due Date *
MM
/
DD
/
YYYY
Siblings' names and ages (if applicable):
Your answer
Phone number *
The best number where we can reach you
Your answer
Alternate Phone Number
If we can't reach you at the number above.
Your answer
Email address *
Your answer
Partner's email address
(Optional)
Your answer
What is your preferred method of contact? *
Required
Street *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
If you have a different mailing address (like a PO box, or if your mailing address has a different zip-code than your residential address, please enter it below)
Your answer
Directions and Notes for visitors *
Is your street and driveway accessible in the winter? Any good landmarks so we can find you easily?
Your answer
Please provide the name, email and phone numbers of an emergency contact person and their relationship to you *
(for example, friend, neighbor, family member)
Your answer
What services are you interested in?
If you are interested in home visits from a volunteer please check some ways you hope your volunteer can help:
If you are requesting a home visit volunteer, what times are you willing to accept support? *
(check all that apply)
Required
Household Information
(For example, do you have any pets? Do any family members smoke? Any food allergies, restrictions, or sensitivities?
Your answer
How did you find out about It Takes a Village? *
Your answer
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