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
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, due date and/or birthdate: *
Your answer
Siblings' names and ages (if applicable):
Your answer
Phone number(s)
Land line; cell; partner's cell
Your answer
Email address(es)
Best email contact; partner's email (optional)
Your answer
Street address, City, State and Zip *
Please include both Mailing Address and Street Address, if different
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 (i.e. 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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