Volunteer Application Please note, we do not accept court-ordered volunteers, including those as part of drug or alcohol-related treatment programs. Individuals with felony charges or convictions are not eligible to volunteer with Meals on Wheels.Name* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you volunteering as part of court-ordered community service or as part of a drug or alcohol treatment program?* Yes No How Did You Hear About Us?* Date of Birth* MM slash DD slash YYYY Home PhoneCell Phone*Email Address* Emergency Contact Name* Emergency Contact Relationship* Spouse, friend, etc.Preferred method of contact?* Phone Text Email Have you ever been convicted of a felony?* Yes No If you have any criminal convictions or charges pending, you are not eligible to volunteer with United Way Meals on Wheels.Reminder Preference* Phone Call Text Email Wireless Provider (Required)*In order for us to call or text message reminders to your cell phone, we must have your wireless provider. AT&T Verizon T-Mobile Are you volunteering as an individual or as part of a group?* Individual Group If group, please provide the additional informationGroup Name Group Contact Name Group Contact Phone NumberGroup Email Volunteer Opportunites of InterestPlease tell us how you would like to volunteer (check all that apply): Meal Delivery (M-F during lunch) Meal Packer/Kitchen Aide (M-F, 8 a.m. to 12 noon) Pantry Packing (Stocking pantry at MOW kitchen) Food Pantry Delivery Client Support: Donate items or host a drive toward most needed items: (For example, Stock Our Pantry, Warm Weather Needs, Blanket & Winter Supplies Drive) Celebrations: Help us celebrate: (For example, Client Birthday Bags, Be a Santa to a Senior) Schedule AvailabilityPlease note: MOW delivery and kitchen-related activities are available only M-F at this time. The delivery of meals is during the lunch hour(s). What days would you like to volunteer? Monday Tuesday Wednesday Thursday Friday How often would you like to volunteerMinimum commitment of one day per month. Once/month Twice/month Once/week Do you have a preferred schedule? Preferred Delivery AreasWhere are you willing to travel for a volunteer assignment?Check all that apply. We currently have 55 delivery routes; some examples are included below. No preference; (put me where I am most needed) Birmingham City (Forest Park, Crestwood, Kingston) Eastern Jefferson County (Irondale, Roebuck) Southern Jefferson County (Homewood, Vestavia, Hoover) Northern Jefferson County (Fultondale, Gardendale, Tarrant) Western Jefferson County (Bessemer, Fairfield, Midfield) If you would like to volunteer within a specific neighborhood, please indicate which one(s): Our PoliciesIt is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age or disability. All volunteers must complete a background screening prior to serving in the program. We do not accept volunteers through court-mandated community services.License and Insurance Information (This section is required for drivers only.)DL Number State Auto Insurance Company Policy Number Policy Expiration Date MM slash DD slash YYYY Agreement and Signature I. AGREEMENT to MAINTAIN CONFIDENTIALITY and REPORT I understand that, as a volunteer, I am required to maintain the confidentiality of clients’ personal health information and the conduct of their personal lives. I also understand that I need to report to United Way of Central Alabama, Inc. (UWCA) any client situations that are potentially life-threatening or indicative of adult abuse. I will also notify my supervisor of any client requests and/or concerns regarding food products, preparation and/or delivery. II. AGREEMENT to HOLD HARMLESS I agree to assume full responsibility for myself and the use of my automobile in the course of making deliveries on behalf of the program and further agree to hold Meals on Wheels of Central Alabama (MOW), Community Partnership of Alabama, Inc. and UWCA harmless and without liability in any claim or cause of action arising out of my service as a volunteer for Meals on Wheels of Central Alabama. I agree to carry insurance on my automobile in an amount that is sufficient to satisfy any reasonably foreseeable claim which may arise out of my duties and responsibilities as a volunteer for MOW and to provide proof of insurance to MOW upon request. III. AGREEMENT to COMPLY with FOOD SAFETY and SANITATION GUIDELINES I agree to keep the cold foods in the cold container and the hot foods in the heated container until I have safely delivered the packaged food into the client’s home. I also agree to wash my hands with hot soapy water before opening the containers for any client needing my assistance. I agree to comply with food delivery guidelines provided by MOW. I have read and agree with the above terms* By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions or other misrepresentations made by me on this application may result in my immediate dismissal. Name* Signature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Interview/Photography ConsentI hereby consent to be interviewed, videotaped, photographed or otherwise have my image or voice recorded by the United Way of Central Alabama, Inc. (UWCA) or any other media representative concerning the operation of the UWCA, any of its agencies, programs or activities, and my participation therein. I hereby give UWCA an absolute and irrevocable right and permission to use any interview, videotape, photograph, or other recording of me or about me in any manner whatsoever, including, but not limited to, the UWCA’s right to reuse, publish and republish said interview, videotape or photograph or any other information about me in whole or in part, individually or in conjunction with other information in any medium whatsoever. On behalf of myself, my family, my heirs, executors and assigns, I hereby release and discharge UWCA from any and all claims, liability or demands of whatsoever kind or nature arising out of, or in connection with, the use of any interview, videotape or photograph which I have consented to herein. I have read and agree with the above terms* I have read the statement above and fully understand its contents. Name* Signature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CAPTCHADate MM slash DD slash YYYY Volunteer Join Meals on Wheels We continue to adjust our operations in order to provide uninterrupted service to our Meals on Wheels clients while keeping our volunteers safe. If you’re interested in becoming a volunteer, please fill out the application below to begin the process. We are currently in need of an ADDITIONAL 500 VOLUNTEERS as we we have resumed daily delivery of hot meals. Now more than ever, we need you to help us deliver a difference to homebound seniors in Jefferson County! Thank you for your interest in helping Meals on Wheels!