First Name *

Last Name *

Best phone number to reach you *

Email Address *

Home/Street Address *

City *

Zip Code *

Do you have any limitations that would affect your volunteer placement? (For example, unable to lift more that 7lbs.) Please explain.

White Bear Area Senior Center

White Bear Area Meals on Wheels

Community Partner

White Bear Lake Area Schools

What mornings are you available to volunteer?

What afternoons are you available?

Time available to volunteer

Emergency Contact - Name and phone number

Matching Gift Program: Does your company participate in a Matching Gift Program for volunteer work?

The above information is correct to the best of my knowledge. I understand that this form is confidential and its contents will not be released to anyone without my written consent. I agree to notify the White Bear Area Senior Program of any changes in the above information.

Some volunteer positions require a background check. Do you give permission for us to initiate a background check (if required)?