Form Center

2. Title II Compliance

   In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website.

4. First Name*
5. Last Name*
6. Email Address*
8. Mobile Phone Number*
9. Address
11. State*
12. City*
13. Zip Code
15. Age Requirements*

    Please select the appropriate box. You must be at least 15 years old (with parental consent) to participate as a volunteer in the program.

    1. I am over the age of 15
    2. I am under the age of 15
16. Volunteer Commitment *

    How long would you like to volunteer for this program?

    1. One time only
    2. Weekly
18. Time Availability *

    This program takes place from 2:30PM-4:00PM every Wednesday

    1. Yes, I can commit to be there from 3:00PM-4:00PM
    2. I am only available part of this time
19. Other Availability *
    Other Availability Start Time

    —

    Other Availability End Time
20. Start Day *
    Start Day
    Select the day you would like to begin
21. Weekly Volunteer*

    How many weeks would you like to volunteer?

    1. 2 weeks in a row
    2. 4 weeks in a row
    3. Ongoing
23. What devices are you proficient in? (i.e. android, I-phone, laptop, etc.)*
24. What programs are you proficient? (i.e. Outlook, Word, Facebook, etc.)*
26. Volunteer Waiver
    Every single volunteer must turn in a signed waiver before participating. You can find the waiver online. Please print and sign the waiver. Return the waiver to our office, 211 Bodem Street in Modesto, using one of the below options.
28. Method for Returning Waiver

    1. Upload Online
    2. Email (sparker@modestogov.com)
    3. In Person (211 Bodem Street, Modesto)
29. Upload Signed Waiver
    Please fill out the form and save it to your device prior to choosing this method.
31. Please read carefully before submitting this document.

    1. I hereby understand I am responsible for showing up on time and will have uploaded a signed waiver to this form or will turn in a waiver upon my arrival at the Modesto Senior Center 211 Bodem Street,
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field