You may complete an application to be one of our volunteers by filling out the form below. Fill out as much information as possible. Fields marked with a red asterisk (*) are required.
First Name *
M.I.
Last Name *
Date of Birth *
Street Address *
City *
State *---AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
Zip *
Home Phone *
Daytime Phone / Message #
E-mail Address *Please leave this field empty.
Do You *OwnRentOther
Home Type *---HouseTown HouseDuplexApartmentMobile Home
Language Spoken in Home *
Years of Education Completed *
Check all that apply for all household members *Salary or WagesAlimony/Child SupportSocial SecuritySelf EmploymentRetirement/PensionMSAOther/InterestNo IncomeGeneral AssistanceReemployment Comp.TANF (AFDC, MFIP)SSIFood StampsHousingMedical Aid/Asst.Veterans Benefits
Number of Persons in Household
Number in Household Employed
Check Any That ApplyFarmMigrantSeasonal Farm Worker
Do you or anyone in your household have any disabilities?YesNo
Check one of the following:Single Parent/FemaleSingle Parent/MaleAdults with childrenSingle PersonAdults onlyOther
Check Any That Apply *Energy AssistanceWeatherizationRental AssistanceJobs for SeniorsHead StartEnergy ConservationHome Improvement LoansJobs and TrainingTransportationOther
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Under current Federal and State legislation your right to privacy is protected. MVAC is asking you to supply us with private information concerning you, your family, and household. By Law you do not have to provide this information. MVAC needs information about you to determine if you can get help from any program. Without information about your household, MVAC may not be able to help you and the help may be late or less than what you may be eligible to receive. The purpose for this information is to inform you of eligibility for all programs at MVAC. MVAC may use information to research, plan, and evaluate programs. Information is used in determining compliance with Federal and State regulation's. MVAC will use this information to make statistical and demographic reports to different agencies and funding sources. Never will information that identifies you or any member of your household be revealed unless you give your written permission. MVAC will also use this information to develop a mailing list. MVAC will use the mailing list to update you on the programs and program changes. At no time will the mailing list be revealed to anyone outside MVAC. To assure that you are being served properly only MVAC Staff whose jobs require the information will have access to it.
MVAC may share this information with state and local welfare agencies, community based organizations, local and state public and private human service agencies, Department of Education, the United States Department of Labor, the United States Department of Health and Human Services and state and local educational programs, as allowed by law.
This Agency will keep this information for seven years from the last date updated with you or until program audits are complete. You have the right to review your records at any time to request changes.
