Madison County Community Heart & Soul Volunteer Application Survey

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* 1. Are you volunteering as:

An individual

Part of a Group

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* 2. Please share your contact information:

Name

Company

Address

Address 2

City/Town

State

ZIP/Postal Code

Email Address

Phone Number

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* 3. In which geographic area do you most relate?

Bevington and zip code 50033

Earlham and zip code 50072

East Peru and zip code 50222 (Walnut Township)

Macksburg and zip code 50155

Patterson and zip code 50218

St Charles and zip code 50240

Truro and zip code 50257

Winterset and zip code 50273

Jefferson Township

Lee Township

I live outside Madison County, and I want to volunteer. (Mark the area above to which you most relate.)

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* 4. In which age group are you?

14 - 18 years

19-24

25-34

35-44

45-64

65-79

80+

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* 5. What is your employment status?

Employed full time

Employed part-time

Not employed

Retired - not employed

Retired - working part-time

Student

Prefer not to answer

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* 6. When do you prefer to volunteer? (Check all that apply)

No day preference

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Sundays

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* 7. What are your hours of availability? (check all that apply)

Mornings

Afternoons

Evenings

Varies

All the times listed

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* 8. What are your volunteer interests? (check all that apply)

Local Organizing Committee (Community Champion)

Helping others

Volunteering alone

Volunteering with others

Special events

Contacting others - recruiting other volunteers

Prefer being team member - not the leader

Enjoy being leader or co-leader on a team

Other (please specify)

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* 9. Check skills or interests around which you would be a volunteer asset in Madison County Heart & Soul: (Check all that apply)

Budgeting | Handling money

Community knowledge

Computer skills (i.e. spreadsheets, word processing)

Conducting meetings

Coordinating volunteers

Creativity

Data Collection

Data Entry

Data Analysis

Facilitating conversations

Fundraising

Graphic arts

Interviewing

Networking

Newsletters | Writing reports

Maintaining records

Organizing

Phone calling | Making contacts

Photography

Problem solving

Publicity | Marketing

Scheduling

Research

Social Media

Videography

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* 10. List other skills, education, training that might be valuable to Madison County Heart and Soul (including a community team)

Skill 1

Skill 2

Skill 3

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* 11. Other than English, what other languages can you speak fluently?

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* 12. What do you hope to give to your community as a Madison County Heart & Soul volunteer?

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* 13. How did you hear about this volunteer opportunity?

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* 14. What additional comments would you like to share with the Heart & Soul teams?

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* 15. Please share your Emergency Contact Information - in case of emergency, we should contact:

Name

Address

City/Town

State

ZIP/Postal Code

Phone Number

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* 16. Additional Information:
Please provide any additional information that we may need to know to ensure your safety (medications, hearing or vision difficulties, ability to understand instructions, medical conditions, etc.)

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* 17. Are you on a Sex Offender Registry?

Yes

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* 18. Are you on the Department of Human Services Child Abuse Registry or been founded of a complaint of child abuse?

Yes

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* 19. Have you ever been convicted or received a deferred judgment for crime (not including traffic ticket)?

Yes

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* 1. Are you volunteering as:

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* 2. Please share your contact information:

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* 3. In which geographic area do you most relate?

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* 4. In which age group are you?

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* 5. What is your employment status?

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* 6. When do you prefer to volunteer? (Check all that apply)

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* 7. What are your hours of availability? (check all that apply)

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* 8. What are your volunteer interests? (check all that apply)

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* 9. Check skills or interests around which you would be a volunteer asset in Madison County Heart & Soul: (Check all that apply)

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* 10. List other skills, education, training that might be valuable to Madison County Heart and Soul (including a community team)

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* 11. Other than English, what other languages can you speak fluently?

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* 12. What do you hope to give to your community as a Madison County Heart & Soul volunteer?

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* 13. How did you hear about this volunteer opportunity?

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* 14. What additional comments would you like to share with the Heart & Soul teams?

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* 15. Please share your Emergency Contact Information - in case of emergency, we should contact:

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* 16. Additional Information: Please provide any additional information that we may need to know to ensure your safety (medications, hearing or vision difficulties, ability to understand instructions, medical conditions, etc.)

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* 17. Are you on a Sex Offender Registry?

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* 18. Are you on the Department of Human Services Child Abuse Registry or been founded of a complaint of child abuse?

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* 19. Have you ever been convicted or received a deferred judgment for crime (not including traffic ticket)?

* 16. Additional Information:
Please provide any additional information that we may need to know to ensure your safety (medications, hearing or vision difficulties, ability to understand instructions, medical conditions, etc.)