Wisconsin and Ozaukee Humane Societies: Survey

General Information

1.

Personal Information:

*

Name:

First Required	Last Required

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

*

Phone Number: Required

*

Gender: Required

*

Date of Birth: Required

Date of Birth:

Remember me.

Children (if applying with a child under 18):

2.

Question - Not Required - Name of child:

3.

Question - Not Required - Child's date of birth:

Month

Day

Year

Employment and Education

*4.

Question - Required - Education background:

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

*5.

Question - Required - Occupation:

*6.

Question - Required - Employer:

*7.

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

8.

Question - Not Required - If yes, please explain:

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

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.

*9.

Question - Required - 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?

Tell Us About Yourself

*10.

Question - Required - What is the reason you want to volunteer?

*11.

Question - Required - Have you previously applied to our organization for volunteer or employment?

12.

Question - Not Required - If yes, please list the date you previously applied and for what position:

*13.

Question - Required - Summarize your experience with animals

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

*14.

Question - Required - What do you hope to gain from your volunteer commitment at the Wisconsin Humane Society?

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

*15.

Question - Required - Do you have any limitations (heavy lifting, limited walking, allergies, etc.)?

16.

Question - Not Required - If yes, please explain:

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

*17.

Question - Required - Skills (ex: teaching, public speaking, demonstration, data entry, photography, group facilitation, drawing, crafts, etc.):

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

*18.

Question - Required - Computer experience (list programs used & comfort level in learning new programs):

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

*19.

Question - Required - Are you comfortable taking directions from others?

Volunteer Interest

Which volunteering opportunities are you interested in?

20.

Question - Not Required - Customer Service:

	Adoption Teammate/Greeter
	Animal Antics - Retail

21.

Question - Not Required - Domestic Animals:

	Dog Walking
	Cat Socialization
	Rabbit & Small Animal Socialization
	RELAX Dog Socialization
	Animal Care Volunteer Dog Shine

22.

Question - Not Required - Wildlife:

	Wildlife Admissions Counselor
	Wildlife Animal Care
	Orphaned Bird Care
	Wings
	Wildlife Artisan

23.

Question - Not Required - Children's Programs:

	Birthday Party
	Camp Critter
	Kids' Night Out
	Outreach
	PAL Program
	Scout Night
	Story Time

24.

Question - Not Required - Additional Positions:

	Foster
	Safe Haven Foster
	Office Hopper

*25.

Question - Required - When will you be available to volunteer? (Please check all that apply.)
Please make between 1 and 5 selections from the choices below.

	Morning
	Afternoon
	Evening
	Weekends
	Weekdays

Volunteer Requirements

*26.

Question - Required - I am willing to make at least a six month commitment to my volunteer program.

*27.

Question - Required - I am able to squat, bend, twist, lift, or stand for long periods when working directly with the animals.

*28.

Question - Required - I am able to read and write.

*29.

Question - Required - I am able to work independently. Volunteers need to be able to work independently. If you cannot work on your own, we may ask you to bring someone that can assist you.

*30.

Question - Required - I understand that I will be placed according to the need of the animals and to match my skill set.

Medical Insurance Information

*31.

Question - Required - Name of Insurer:

*32.

Question - Required - Policy Number:

*33.

Question - Required - Insurer's Telephone Number:

*34.

Question - Required - Physician's Name:

*35.

Question - Required - Physician's Phone Number:

Emergency Contact

*36.

Question - Required - Emergency contact:

*37.

Question - Required - Emergency phone:

38.

Question - Not Required - Emergency cell phone:

*39.

Question - Required - Relationship to emergency contact:

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.

*40.

Question - Required - I agree to the above waiver of liability

If you are a parent or guardian applying for a minor, you agree to the following: I give permission for my child to participate in the volunteer program at the Wisconsin Humane Society. I release and hold harmless the Wisconsin Humane Society, its agents, and employees from responsibility or liability arising out of my child’s participation. I understand there are certain risks inherent in dealing with animals. I certify that my child is covered under my health insurance policy should injury take place while volunteering or participating and I will be responsible for his/her medical bills.

41.

Question - Not Required - I agree to the above parental consent statement.

Volunteer Application