HUMANE SOCIETY OF MONROE COUNTY Volunteer Application Our Mission: The mission of the Humane Society of Monroe County

is to provide a safe and healthy temporary home for the lost or stray animals and to seek superior permanent homes to ensure their long-term welfares. Through education and advocacy, the Humane Society of Monroe County will promote the humane treatment of companion animals and will work toward reducing and ultimately eliminating pet overpopulation in Monroe County. Todays date: ____/____/____ Name__________________________________________________ Address________________________________________________ City__________________________ Work phone ( ) ____________ Zip______________ Home phone ( ) ____________

Email Address_______________________ Date of birth____/____/____ Do you have a valid drivers license? Yes No No

Is the car you are driving covered by liability insurance? Yes

If yes, please give name of the insurance company______________________________ Are you guilty of a traffic violation? Yes No

If yes, please explain______________________________________________________ Have you ever been convicted of a criminal offense? ____________________________ If yes, please explain______________________________________________________ Are you presently employed? Yes No

If so, please give us the name and address______________________________________ ________________________________________________________________________

Last tetanus shot ____/____/____

Any physical limitations? ____________________

TIME AVAILABILITY Please indicate the days and times when you would be available: Monday _________________________ Tuesday _________________________ Wednesday ______________________ Thursday ________________________ When is the best time to reach you? (check all that apply) at work at home days evenings Friday ___________________________ Saturday _________________________ Sunday __________________________

Are you volunteering to fulfill Court-Ordered or school related Community Service? Yes No If Yes, for what reason? ________________________________________________ ______________________________________________________________ Number of hours required___________ Date Assigned: _________________ Date by which to be completed: _______________________ Describe any training experience, or formal education in animal care or welfare you have had that might help you in your volunteer assignment: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ List the skills and experience you have that you can contribute to this organization, i.e. typing, what areas of computer knowledge etc: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

Please place a check mark next to your areas of interest below Shelter volunteer positions: ____dog kennel assistant ____shelter repair and maintenance ____ cat room attendant ____assist with landscaping ____daily laundry ____snow removal and lawn mowing ____daily cleaning ____foster parent ____answer phones ____can and bottle return ____assist with clerical work ____computer (all areas) ____assist with digital photography ____vet tech skills ____assist with dog training ____dog and cat grooming ____assist with transportation to veterinary appointments Community volunteer positions: ____assist with adopt-a-thons ____dog walk ____assist with community education events ____assist at the auction ____assist with visits to schools/Alterra ____ Santa paws pictures ____public speaking ____mall holiday booth ____assist at educational events ____perennial sale ____crafting and baking (fundraisers) ____vaccine clinic ____assist at the fair booth ____garage sale Administrative office: ____public relations experience ____computer experience (all areas) ____contact volunteers ____grant writing experience ____digital photography

____assemble newsletter ____office cleaning ____answer phones ____assist with graphic design ____artistic talents ____marketing experience

I am willing to travel for events to: South County ____ Toledo____ Detroit Zoo____ Monroe area only ____ Please check one of the following: I prefer to work with ___People ___Animals ___Both people and animals. Drivers license #_______________________________ Proof of car insurance____________________________ Emergency contact: Name _______________________________ Relationship_____________________ Phone ( ) ______________ Reference: Name______________________________ Phone ( ) ________________ length of relationship___________ Work ( ) ___________________

Work ( ) ___________________

Name______________________________ Phone ( ) ________________

length of relationship___________

Work ( ) ___________________

Name______________________________ Phone ( ) ________________

length of relationship___________

Work ( ) ___________________

For Office Use Only: Contacted by___________________________ Date________________ Results and comments:

HSMC Waiver for Volunteers In signing this application, I understand and agree to the following: I am at least 16 years old. I agree to attend all training classes. I agree to be supervised by another volunteer or staff person. I give the Humane Society of Monroe County permission to use photographs or video footage of my volunteer activities should it benefit the volunteer program or the organization. 5 I understand that if I am injured while acting as an unpaid member of the volunteer staff, I am responsible for my own medical expenses and I am not covered by the Humane Societys Workers Compensation insurance or any other insurance through the Humane Society of Monroe County. 6 I understand that as a volunteer, I may gain access to information about the organization, customers, or staff that is confidential. I agree to respect and maintain the confidentiality of all donors, customers, volunteers, staff and other individuals working with the Humane Society of Monroe County both on and offsite, during and outside of volunteer hours. 7 As a volunteer of the Humane Society of Monroe County, I understand that I must carry my valid drivers license and current automobile insurance to drive any vehicle while on Humane Society business, such as errands, pet transports, bottle returns, etc. If my driving or insurance status changes in any way, I agree to notify the Humane Society Director immediately. I agree to abide by the Humane Society of Monroe County staff/volunteer driving policy. 8 There are certain risks inherent in handling the animals and I accept these risks. Volunteer Release Agreement And Covenant Not To Sue: I, the undersigned, do hereby agree to release the Humane Society of Monroe County from all liability. I will not hold the Humane Society of Monroe County liable for any damage, illness or injury sustained during volunteer work. I, the undersigned, will never institute any action or suit at law or in equity against the Humane Society of Monroe County, nor institute, prosecute or in any way aid, assist, or participate, directly or indirectly, in the institution or prosecution of any claim, demand, action or cause of action for damages, costs, loss of services, expenses, or compensation for or on account of any damage, loss or injury either to person or property, or both, whether developed or undeveloped, resulting or to result, known or unknown, past, present, or future, arising out of the condition or operation of the Humane Society of Monroe County and its facilities (including but not limited to any damage, loss or injury either to person or property, or both, resulting from contact with or the action or conduct of any animal located at or in the custody or control of or in releases, demises, and discharges the Humane Society of Monroe County). 1 2 3 4

The undersigned volunteer further hereby releases, demises, and discharges the Humane Society of Monroe County and covenants and agrees to defend, indemnify and hold the Humane Society of Monroe County harmless of and from demands, damages, suits, costs or expenses said volunteers had or may have for any reason or which may occur or arise by reason of volunteers association, activity or work now, heretofore or hereafter at or with the Humane Society of Monroe County. I certify that the statements made in this volunteer application are true and have been given voluntarily.

Name (please print)

Address

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State

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Student Volunteer Signature

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Parent or Guardian Signature

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Witness

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