Wisconsin and Ozaukee Humane Societies: Survey - Pets for Life Volunteer Application

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.

Employment and Education

*2.

Question - Required - Education background:

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

*3.

Question - Required - Occupation:

*4.

Question - Required - Employer:

*5.

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

6.

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.

*7.

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

*8.

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

*9.

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)

*10.

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

11.

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

*12.

Question - Required - Summarize your experience with animals

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

*13.

Question - Required - Please summarize your experience working with an underserved community or population.

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

*14.

Question - Required - In this position, you will see animals in less-than-ideal conditions. Please explain how you would work with these pet's owners in non-judgmental manner.

(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 - Special skills (e.g. teaching, public speaking, data entry, photography, phone commuication, etc.):

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

*18.

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

*19.

Question - Required - Which volunteering opportunities are you interested in? (Select all that apply. We encourage volunteers to be involved in both roles, but it is possible to volunteer for one opportunity only based on interest and availability).
Please make between 1 and 2 selections from the choices below.

	Community Outreach Street Team
	Community Outreach Events

*20.

Question - Required - When will you be available to volunteer? (Please check all that apply.)
Please make between 1 and 4 selections from the choices below.

	Mornings
	Afternoons
	Weekdays
	Weekends

Volunteer Requirements

*21.

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

*22.

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

*23.

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

*24.

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.

*25.

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

*26.

Question - Required - Name of Insurer:

*27.

Question - Required - Policy Number:

*28.

Question - Required - Insurer's Telephone Number:

*29.

Question - Required - Physician's Name:

*30.

Question - Required - Physician's Phone Number:

Emergency Contact

*31.

Question - Required - Emergency contact:

*32.

Question - Required - Emergency phone:

33.

Question - Not Required - Emergency cell phone:

*34.

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.

*35.

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