Volunteer First Name Last Name Phone Number Email Volunteer Information What kind of volunteer work are you interested in? / ¿Qué tipo de trabajo voluntario le interesa hacer? Food Distribution / Distribucíon de Comida Food Packaging / Envase de Alimentos Social Media / Redes Sociales Fundraising / Recaudación de Fondos Food Pantry Availability / Despensa de Alimentos: Disponibilidad Mondays 8:30 AM - 11:30 AM Food Bagging in person Mondays 9:30 AM - 12:30 PM Food Bagging/ Food Distribution Tuesdays 8:30 AM - 11:30 AM Food Distribution in person Tuesdays 9:30 AM - 12:30 PM Food Distribution in person Tuesdays 10:30 AM - 1:30 PM Food Distribution in person Wednesday 9:30 AM - 12:30 PM Food Distribution in person Wednesday 10:30 AM - 1:30 PM Food Distribution in person Third Saturday of every Month 8:30 AM - 12:30 PM Food Distribution in person Third Saturday of every Mont 9:30 AM - 1:30 PM Food Distribution in person Third Saturday of every Mont 10:30 AM - 2:30 PM Food Distribution in person Senior Service Program - NORC / Programa de Servicio para Personas Mayores NORC Mondays 8:00 AM - 1:00 PM Front Desk/Receptionist Volunteer Mondays 9:00 AM - 12:00 PM Outreach Volunteer Wednesdays 9:00 AM - 12:00 PM Outreach Volunteer Thursdays 9:00 AM - 12:00 PM Outreach Volunteer Thursdays 1:00 PM - 3:00 PM Outreach Volunteer Spoken Languages What languages do you speak? / ¿Qué lenguas habla? English Spanish Chinese Mandarin Chinese Cantonese Arabic French French Creole German Greek Hebrew Hindi Italian Korean Polish Russian Tagalog Urdu Yiddish Other If other language Skills or Resources Do you have any special skills, resources, or anything else you'd like to offer our membership that wasn't listed above? / ¿Tiene otras habilidades, recursos o algo más que no esté en la lista de arriba que le gustaría ofrecer a nuestra membresía? Have you been vaccinated? If so, which vaccine? Moderna Pfizer Johnson & Johnson Have you received your second shot? Yes No COVID-19 INFORMATION A vast majority of our food pantry recipients are elderly. In order to protect everyone involved in this project, please answer honestly. All answers will remain confidential. I have tested positive for Covid-19, and am currently experiencing symptoms. I have tested positive for Covid-19, and am NOT experiencing symptoms. I have recovered from Covid-19, more than 14 days ago. I have recovered from Covid-19 less than 14 days ago. I haven't been tested, but am feeling symptoms I have not been tested, and have no symptoms I have been tested, and I have tested negative Other COVID-19 INFORMATION: if other We are growing and we need your help! Will you allow us to send you information about upcoming volunteer opportunities? Yes! I am excited to help you grow! No thank you, if I want to help in the future I will contact you. FOOD PANTRY VOLUNTEER AGREEMENT, CONFIDENTIALITY & RELEASE FROM LIABILITY * I am agreeing to work as a volunteer for VISION URBANA, INC. I understand that I will have access to certain sensitive information about the clients served which may include financial, medical, health, living situation, and other sensitive and/or confidential records/information. I agree to keep all information confidential during and after my volunteer shift, and will not disclose information pertaining to any client, for any reason other than to serve the client under VISION URBANA, INC.'s care. I understand that if I breach this agreement, I may be faced with a civil liability or penalty for breaching a client's right to privacy. I acknowledge my obligation to respect the client's privacy and the required confidentiality of the information pertaining to the food pantry client. As a volunteer I am aware that my participation may require physical activity (i.e.: standing, lifting, pulling/pushing carts, carrying items up to 40 lbs., traveling in stairways, and/or walking to destinations, etc.). I will use a reasonable caution to avoid injury to myself and others. I am volunteering and participating in this activity with knowledge of the hazards and potential dangers involved, and agree to accept any and all risks of personal injury and property damage inflicted by me. I understand that the tools and materials provided by VISION URBANA , INC., are and remain the property of VISION URBANA, Inc., and I agree to return any tools, materials, or items back to VISION URBANA, Inc., at the end of my volunteer service. I agree to the terms as set forth above and am excited to Volunteer! I DO NOT agree, and I no longer want to volunteer. Thank You / Gracias Thank you for your interest in volunteering with Vision Urbana. We will call/text/email you with available volunteer opportunities that match your skills with the needs of our organization and community. Muchas gracias por su interés en voluntariar con Vision Urbana. Le contactaremos para indicarle que oportunidades para voluntariar de acuerdo a sus habilidades y las necesidades de la organización.