Adult & PYPer Volunteer Application

Please complete our online application form if you are interested in joining the SICSA Pack to help us save lives.

Once you have submitted the form, you will be redirected to the SICSA Volunteer webpage.

If you encounter problems while completing this form, we recommend emailing volunteer@sicsa.org for assistance, instead of phone calls.

Contact Information

Legal First Name:

*

Last Name:

*

Middle Initial:

Title:

Nickname or Preferred:

Primary Address:

*

Secondary Address:

City:

*

State:

* Zip: *

Primary phone:

* OK to call me here

Secondary phone:

OK to call me here

Supplemental phone:

OK to call me here

Email address:

*

Volunteer Background & Interests

The information collected in this section will be used to provide a more meaningful and fulfilling volunteer experience to you as well as SICSA by maintaining efficient processes by matching available opportunities to your areas of interest. You may update this information in your Volunteer account at any time following your orientation and will obligate you to any particular tasks or assignments.

NOTE: Those with prior felony convictions must disclose the date(s) and nature of those offense(s). Any and all information provided is strictly confidential. Anyone convicted of violent offense(s) against humans and/or animals, aggravated theft, aggravated arson, weapons and/or drug trafficking charges will cannot be admitted in to SICSA's Volunteer programs. Background checks may be required. All those currently under a Labor & Industry claim must disclose that information as well as anyone that has been released from any other volunteer programs previously. Persons having been found withholding this information will be removed immediately.

Emergency Contact Information

First name:

*

Last name:

*

Street 1:

Street 2:

City:

State:

Zip:

Primary Phone phone:

*

Secondary Phone phone:

Relationship:

Parent-Youth-Partner(PYPer) Volunteer Information

Please complete this section if you will be volunteering with a child* between the age of 8 and 12 through our PYPer program.

If not, please skip and proceed to the next section.

*Up to two children per adult or guardian Volunteer.

1st PYPer T-shirt Size:

2nd PYPer T-Shirt Size:

1st PYPer Child Name::

1st PYPer Child DOB::

2nd PYPer Child Name::

2nd PYPer Child DOB::

Employer Information

Any information provided in this section will be used to help SICSA identify opportunities for grants, corporate volunteer programs, matching gifts or company equipment and/or financial donations to support the ongoing care of our animals.

Employer:

Street 1:

City:

State:

Zip:

Primary Phone phone:

OK to call here

Secondary Phone phone:

Email address:

Workplace Employee Volunteer Program?:

Release of Liability & Assumption of Risk

By electronically signing this Release of Liability and Assumption of Risk(the Agreement), I hereby agree to, acknowledge and give my consent without reservation to the following on my own behalf, as of the date set forth below.

1. I have voluntarily enrolled in, and voluntarily agreed to participate in, certain activities occurring on behalf of SICSA Pet Adoption & Wellness Center(SICSA), both on and off SICSA's premises, as part of the Volunteer Program(the Program). I understand and agree that my acceptance of the terms and conditions of this Agreement, and my strict adherence to the established rules, guidelines and protocols of SICSA, are conditions of my participation in the Program. I understand that my privileges may be revoked or suspended at any time for non-compliance or safety issues, or for my breach of this Agreement in any way, as may be determined by SICSA in its sole discretion.

2. I understand that I and/or the child(ren) in my care will be interacting with animals belonging to SICSA and/or its staff, volunteers or affiliates with adult supervision. I understand that animals, even under the best of circumstances, may be unpredictable, may bite or scratch and may transmit zoonotic diseases. I understand that SICSA specifically recommends that visitors to SICSA's premises maintain current tetanus vaccinations and that I am encouraged to consult with a medical professional to decide whether or not I or the child(ren) in my care should be vaccinated against tetanus and to properly address any medical questions or concerns prior to my participation in the Program.

3. I understand that my attendance is purely voluntary and not without risk of injury, including but not limited to, serious physical harm to me or the child(ren) in my care. I recognize and agree that SICSA, together with its officers, directors, instructors, agents, volunteers, employees, predecessors, successors, affiliates and representatives(collectively, the Released Parties), assumes no responsibility for any liability, damage, expense(including medical care), cost, fee(including attorneys fees), claim, demand, loss, obligation, settlement agreement, injury or illness, suit at law or in equity, whether in whole or in part, foreseeable or unforeseeable, known or unknown, fixed or contingent, suspected or claimed, that I or the child(ren) in my care may have ever had or now have against the Released Parties arising from or otherwise relating to myself or the child(ren) in my care's participation in the Program or my decision to permit the child(ren) in my care to participate in the Program(collectively, the Claims), including but not limited to, any Claims caused directly or indirectly by any negligence(active or passive) attributable to the Released Parties or my decision to not vaccinate myself or the child(ren) in my care against tetanus or any third-party Claims brought by my guest(s), if any. For the avoidance of doubt, I agree that if I or the child(ren) in my care are injured on SICSA's premises in any capacity whatsoever, I am aware that my own health insurance coverage will provide for any necessary medical treatment or care for myself and the child(ren) in my care.

4. In consideration of, and as an inducement to, the acceptance of my or the child(ren) in my care participation in the Program, and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I(together with my spouse, heirs, successors, executors, administrators, agents, personal and legal representatives and assigns) agree to forever release, discharge, indemnify, and hold harmless the Released Parties for any and all Claims.

5. I understand that I and the child(ren) in my care are expected to treat all property located at SICSA s facilities with respect. I recognize that I am solely responsible, financially and otherwise, for the actions or inaction of myself and the child(ren) in my care while participating in the Program, and I agree to assume full financial responsibility for any and all damages to, or losses of, the real or personal property of SICSA or any third party caused directly or indirectly, in whole or in part, whether or not foreseeable, by myself or the child(ren) in my care, as determined by SICSA in its sole and absolute discretion, and I further agree to indemnify and hold harmless the Released Parties from any third-party claims related thereto.

6. In the event that I or the above-named alternate emergency contact cannot be reached to make arrangements for emergency medical attention for myself or the child(ren) in my care, I authorize SICSA to act on my behalf with respect to the provision of such care, and I consent for any and all treatment. I agree to pay all costs and expenses incurred in connection with any medical care provided, including the cost of transportation.

7. I understand that public relations are an important part of the activities conducted at SICSA. Thus, SICSA has permission to use without notice or compensation my likeness and/or the likeness of the child(ren) in my care in any and all social media, photographs, video and images, and to further include my/his/her name in any materials that promote SICSA's services and programs, or to publicize any event, or for any other lawful purpose(including but not limited to, the right to edit, alter, copy, publish or distribute). I understand and agree that all film, prints and negatives become the sole property of SICSA and may be used by SICSA without payment or royalties or any other consideration or prior notification.

8. This Agreement supersedes all prior discussions, representations, warranties and agreement, and expresses the entire agreement between SICSA and me regarding the subject matter herein. This Agreement may be amended only by a written instrument signed by both parties. This Agreement shall be interpreted in accordance with the laws of the State of Ohio. All claims, disputes and lawsuits arising out of or in connection with this Agreement shall be resolved or adjudicated in Montgomery County. If any provision of this Agreement is deemed invalid, void or unenforceable, such provision shall be considered severed from the Agreement and the remaining provisions shall be given full force and effect.

I understand that my or the child(ren) in my care participation in the Program is contingent upon this Agreement being signed electronically below by me and my completion of all personal information requested above. By signing below, I acknowledge that I have read and fully understand the terms and conditions of the foregoing Agreement. My electronic signature below is valid as if it were an original signature. By submitting this application with my electronic signature, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my dismissal from the volunteer program.

I Agree