Bloomington Meals on Wheels Volunteer Application
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Name *
Address *
City *
State *
Zip Code *
Phone number(s) *
Phone Type *
Alternate phone number
Phone Type
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Email Address *
Date of Birth *
Which volunteer opportunities are you interested in (Check all that apply)
Days available to deliver meals or pack bags: *
Would you be willing to drive in bad weather? *
Special Needs/ Physical limitations:
Are you fully vaccinated against COVID-19? (2 weeks past final required dose)  You will not be denied based on responding no. This question is to help identify volunteer partners for those who wish to partner with a vaccinated individual. *
In addition to being assigned to a regular day route, would you be willing to drive occasionally when a substitute driver is needed? *
Would you prefer to volunteer only as a substitute driver? *
Current employer (if retired, last employer) *
Do you have a valid driver's license? *
Driver's license number and issuing state: *
Do you have a vehicle to use for meal delivery? *
Does the vehicle meet minimum state insurance requirements? *
Vehicle insurance company and policy number: *
Is your vehicle legally registered? *
Have you ever been convicted of a felony, crime of dishonesty or untruthfulness, or a crime involving abuse of alcohol or a controlled substance? If yes, please describe in detail below. *
By writing my name below, I hereby authorize Bloomington Meals on Wheels or any of its agents to perform a criminal background check or any other kind of background check.  I also agree that the above statements are true and correct. *
Date completed *
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