Wisconsin Veterans Home at King

N2665 County Rd QQ

King, Wisconsin 54946-0600

(715) 258-5586
VOLUNTEER GROUP INFORMATION
Name of Group:
Person to Contact:
Phone:	Email:
Address:
City, State, Zip:
Number of People in Group:
If Children in Group - How Many?	Ages?	Grades?
If Children in Group - Will there be Volunteers Along with the Group?	How Many?
Preferred Day of Week/Date(s)/Time(s) to be here?
*Please Note: We may not be able to accommodate the exact date. If we are unable to accommodate the exact date, we will get back to the group with alternate choices.
Planned Arrival Time:	Planned Departure Time:
Type and Number of Vehicles:
What is the Group Interested in Doing Here?
Tour Facility
Sponsor, Perform or Run an Activity i.e. Bingo, Music Performance?
Where: in Building at Marden in Park
What:
Who is supplying funds?
Treats?	If yes, who is supplying?
Visit 1:1 with Members
Do an intergenerational activity in a Building?
What type? game/craft, etc.
Sponsor King Members at a Different Location
Where and what for?
How many members would you like to attend?
Any specific criteria for member attendance? i.e. male/female or veteran?
Is there accommodations for wheelchair members?
Approximate length of trip?
Will there be volunteer supervision or staff attending the trip?
Meal offered?
Is the Group Donating Items?	What?
Other:

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WVH-KING STAFF PERSON ON INITIAL CALL:
DATE:
DATE ENTERED INTO LOG:
REFERRED TO:
DATE:
NOTES:

WDVA #### (03/06) Page # of #

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WDVA 3125 (06/09)

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Forms Template - DVAK Portrait

Cindy Thompson

2009-06-03

Department of Veterans Affairs