Wisconsin and Ozaukee Humane Societies: Survey

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Please provide the following information:

Name:

Title	First Required	Middle Required	Last Required	Suffix

Email: Required

Street 1: Required

Street 2:

City/State/ZIP:

City Required	StateRequired	ZIPRequired

Country:

Phone Number: Required

Employer: Required

Occupation: Required

Gender:

Date of Birth: Required

Month

Day

Year

Yes, I would like to receive e-mail from Wisconsin and Ozaukee Humane Societies

Email Format:

Yes, I would like to receive postal mail from Wisconsin and Ozaukee Humane Societies

Remember me.

Work Phone:

Can we contact you at work?

Emergency contact:

Emergency contact phone:

Educational background:

Previous and current volunteering experience:

Summarize your experience with animals.

What do you hope to gain from your involvement in the Guardian Animal Network?

Please check any limitations you might have.
Please make up to 4 selections from the choices below.

	Heavy Lifting
	Limited Mobility
	Allergies
	Other

Please give details of your limitations here.

(Maximum response 255 chars, approx. 5 rows of text)

How do you work best?
Please make between 1 and 3 selections from the choices below.

	Alone
	With Staff
	With the Public

Have you been convicted of a misdemeanor or felony in the last seven years?

If yes, please explain.

(Conviction may not necessarily disqualify you from volunteering. We may conduct a background check and if you do not provide complete and truthful information, you could be rejected or terminated.)

Safety is our number one priority for staff and volunteers. Due to certain risks inherent in handling animals, personal health insurance coverage is required to volunteer at the Wisconsin Humane Society.

Do you have personal health coverage?

How did you hear about us?
Please make 1 selections from the choices below.

	Advertisement
	Website
	Our newsletter
	A friend or volunteer
	Other

Do you have any other comments you'd like to make?

By typing your name in the space provided below, you agree to the following:

In consideration of WHS accepting my application for participation in WHS programs, I agree to release and hold harmless WHS 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 WHS' programs. I understand there are certain risks inherent in handling animals and I accept those risks. 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.

I agree that WHS may photograph my participation in this program, and I hereby release any such photographs to WHS for use in its programs, publications and purposes.

I agree to the above waiver of liability (type your name here).