Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Full Name *Address *Phone *Email *City/State/Zip *Are you 18 years old or older? *YesNoHow did you hear about our program? *I understand that Meals on Wheels are served only week days during the early lunch hours. *YesNoWhat meal site would you prefer to pick up from? *Click drop down to select preferred location. Broadway Station – North FargoOlivet Lutheran Church – South FargoEd Clapp Park Senior Center – South FargoCalvary Fargo Church – South FargoWest Fargo High Rise – West Fargo---RURAL CASSMartin's Lutheran Church - Casselton---RICHLAND COUNTYWahpeton Senior CenterAbercrombie Community CenterHankinson Senior CenterLidgerwood Senior CenterWyndmere Senior Center---RANSOM COUNTYLisbon Senior CenterEnderlin Senior Center--SARGENT COUNTYRutland Community CenterForman Senior CenterCogswell Community CenterMilnor Senior Center---TRAILL COUNTYHillsboro Senior CenterBuxton Senior CenterMayville Senior CenterGolden Age Club - Portland---STEELE COUNTYFinley Senior CenterReasons for volunteeringSignatures To volunteer with Valley Senior Services, applicants need to pass a background check. While the application is being considered, you can expect an email from the Fargo Park District to collect necessary information for the background check, since VSS is a branch of the Fargo Park District. A link is provided for you to submit information, including your social security number, in order to process the background check. If you have questions, contact the Valley Senior Services office at 701-293-1440 or mealsonwheels@fargoparks.com. By signing this application, I hereby verify that the information listed above is accurate. I understand that Valley Senior Services is not responsible for any accidents or injuries while volunteering. I will keep all information about Meals On Wheels clients confidential and understand that the unauthorized release of this information without proper consent of the client and notification to Valley Senior Services will result in termination and other consequences. I authorize the Fargo Park District and Valley Senior Services to conduct a background check of me should I be selected for a volunteer position with Valley Senior Services Meals On Wheels program. I release and hold the Fargo Park District and Valley Senior Services harmless from and against any liability and damage(s) that may result from Valley Senior Services use of such information. I understand by completing this application, there is no contractual or implied agreement between myself and Valley Senior Services. Signature * Clear Signature Permission to Use Photograph I grant to Valley Senior Services, its representatives and employees the right to take photographs of me in connection of volunteering. I authorize Valley Senior Services, its assigns and transferees to copyright, use and publish the same in print and/or electronically to promote and encourage the involvement in the organization from the community. I agree that Valley Senior Services may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content. I also agree no materials need to be submitted to me for any further approval. I also understand as a volunteer, I represent Valley Senior Services while delivering Meals on Wheels. I will not take video or photographs of recipients of meals or other volunteers without written or verbal consent. I also understand I will need the consent of Valley Senior Services to publish, post or share stories and/or photos taken. I understand the protection of confidential information is vital to the interest and success of Valley Senior Services (VSS). Therefore it is VSS policy that the volunteers will not discuss any client information they gain. I have read and understand the above: Signature Clear Signature Submit
