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, Family Services Manager
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:
I live in one of our "Hilltowns" (check map here:
I am going to have a baby soon, or have a baby under the age of 1 year
Name of person filling out this form
Name(s) of partner(s) or other adults living in the home
Baby's name, due date and/or birthdate:
Siblings' names and ages (if applicable):
Land line; cell; partner's cell
Best email contact; partner's email (optional)
Street address, City, State and Zip
Please include both Mailing Address and Street Address, if different
Directions and Notes for visitors
Is your street and driveway accessible in the winter? Any good landmarks so we can find you easily?
Please provide the name, email and phone numbers of an emergency contact person and their relationship to you (i.e. friend, neighbor, family member)
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:
Housework (dishes, laundry, vacuuming, etc...)
Holding your new baby while you sleep/shower/etc.
Playing with your older child
If you are requesting a home visit volunteer, what times are you willing to accept support?
(check all that apply)
Week day mornings
Week day afternoons
(For example, do you have any pets? Do any family members smoke? Any food allergies, restrictions, or sensitivities?
How did you find out about It Takes a Village?
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