HUMANE SOCIETY OF MORGAN COUNTY VOLUNTEER APPLICATION

Do you have a truck?   YES NO

Name:

Address:

City, State, Zip:

Home phone: Work phone:

Cell phone: Are you 16 or older?  YES NO

Email address:

Employer name: May we contact you at work?

Why are you interested in becoming a volunteer at the shelter?

List any special skills you have that would be valuable to the shelter:

What experience do you have with animals?

What pets do you currently own or have owned in the past?

Have you ever had an animal complaint filed against you?  YES NO

If so, please explain:

Which areas of the shelter would you like to volunteer for?

What things do you NOT want to do?

When are you available? (Please be sure to indicate morning or afternoon, and the day of the week)

Do you have any physical limitation or health restrictions of which HSMC should be aware?
YES NO   If so, please explain:

Emergency contact: Phone number:

Physician name: Phone number:

I, as a volunteer service provider to the HSMC, hereby acknowledge knowingly, freely and voluntarily waiving my right or cause of action of any kind whatsoever arising as a result of such activity from which any liability may or could occur against HSMC or its agents or employees jointly or individually. I declare that I shall not hold the HSMC liable for any illness, injury or disease that I might contract or sustain while I am working in said capacity. I also understand that I am not covered under workers' compensation. I fully recognize the dangers associated with the work of the HSMC and I freely consent to this waiver. The HSMC makes no representations concerning any animals' exposure to rabies or other diseases.

My printed name below serves as my signature binding me to these terms:

Print full name: Date: