Date

Name

Address

City, State, Zip

Home Phone

Work Phone

Cell Phone

Email Address

Preferred method of contact and best time to reach you

Birth Year (yyyy)
Occupation

Days Available
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Hours available

Additional comments regarding availability

General skills and experience that might be beneficial as a volunteer

Describe any animal experience

Do you have any physical limitations, if so please describe. Do you have allergies to dogs or cats?

Do you currently own pets? If so are they spayed and neutered? Current on vaccinations, and on heartworm prevention?

What vet clinic do you use? Name, address, phone number

Have you volunteered with an animal related group before? If yes, with what organization(s)? Please list contact information for that organization(s)

I agree to comply with all the rules and regulations established by HCHS, and I understand that failure to do so may result in my immediate termination as a volunteer. As a volunteer, I agree to do my best to represent HCHS to the public in an accurate and professional manner.

I understand that if I am or become pregnant while volunteering at the HCHS or have medical conditions that compromise my immune system, that I should talk to my doctor and get my doctor’s approval to volunteer in an animal shelter.

I agree that HCHS may photograph my participation with HCHS, and I herby release any such photographs to HCHS for use in its programs, publications and purposes.

By signing below, I certify that all statements in this volunteer application are true and have been given voluntarily. I understand that my participation in any of the above named volunteer positions is strictly on a volunteer basis without pay or compensation of any kind and that volunteers are not classified as employees, agents or servants of the Henry County Humane Society and thus any injuries I might sustain during the course of my volunteer activities are not entitled to coverage under the Henry County Humane Society’s worker’s compensation policy. I agree to release and hold harmless the Henry County Humane Society from and against any and all loss, damage, claims, liability, costs and expenses of any nature whatsoever, including without limitation, attorney’s fees and disbursements, arising from or occasioned by my participation in the Henry County Humane Society’s volunteer program. I recognize that in handling animals and performing other tasks, there are certain risks inherent of injury including physical harm caused by the animals. I agree to release and hold harmless HCHS and any of its officers, directors, employees, affiliates, agents, volunteers, representatives, successors and assigns from and against any and all loss, damage, claims, liability, costs and expenses of any nature whatsoever, including without limitation attorney’s fees and disbursements, arising from or occasioned by my services to HCHS. I understand if an accident or injury should occur, no matter how minor, that I will complete a Volunteer Injury Report form and seek any necessary medical attention utilizing my own medical insurance.

By checking the box below, I submit this application with my electronic signature