COMMUNITY SERVICE APPLICATION

Thank you for your interest in completing your community service hours with the Humane Society of Sedona. Please complete this application and click the submit button at the bottom when you are done. All information provided will be kept confidential.

DATE OF APPLICATION

Please enter today's date here:

NAME

Please enter your full name as well as your preferred name or nickname if you have one.

First name:

Last name:

Nickname:

CONTACT INFORMATION

Please include your full mailing address, phone number (s), and email address below.

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Home phone:

Work phone:

Cell phone:

Email address:

DEMOGRAPHICS

This information is used for internal tracking and will not be given out.

Date of birth:

Age:

Gender:

Education:

YOUTH VOLUNTEERS (UNDER AGE 18)

If you are under the age of 18, please list the name of a PARENT/GUARDIAN below. You must be at least 16 years of age to volunteer at the Humane Society of Sedona on your own. HOWEVER, if you are 13-15 you may volunteer as long as you are accompanied by a parent or guardian.

BACKGROUND

Have you been convicted of a felony in the past 7 years? (A "YES" response does not automatically disqualify you)

Please indicate YES or NO here:

If YES, please explain:

OCCUPATION

Please list your current occupation as well as any occupations you have done for a number of years. If you are retired please list your occupation(s) before you retired.

Occupation:

Use this box if you need more space:

SKILLS, HOBBIES, INTERESTS

Please check any skills you may have on the list below. Use the empty box to add in any skills, hobbies or interests you feel may be pertinent. This will help us match you to the many volunteer opportunities we offer.

EMERGENCY CONTACT

Please list at least one person as an emergency contact. List the person's name, relationship to you, and a phone number they can be reached at.

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

AVAILABILITY

Please indicate your availability below.

COMPLETE FOR COURT ORDERED COMMUNITY SERVICE

This section is REQUIRED for court ordered community service. Please provide the information for each of these items in the box below:

1. OFFENSE for which you received community service

2. COURT NAME; City/County

3. NUMBER OF HOURS needed

4. WHAT DATE these hours are due by

VOLUNTEER AGREEMENT & WAIVER OF LIABILITY

VOLUNTEER AGREEMENT

As a volunteer with The Humane Society of Sedona (HSS), I agree to….

✓ Always treat the animals with kindness, patience, and a gentle hand. I will always speak to them softly in a friendly tone of voice. I will always exercise compassion and care with the animals.

✓ Hold confidential all information that I may obtain, directly or indirectly, concerning donors, guests, volunteers, animals and staff. Become familiar with HSS policies and procedures, and uphold their philosophy and standards. I will seek clarification from the appropriate staff when required.

✓ Donate my services to HSS without contemplation of compensation.

✓ Refrain from taking personal photographs on HSS property, and any involvement with members of the media unless otherwise approved by appropriate staff.

✓ Be punctual and conscientious, conduct myself with dignity, courtesy, and consideration for others, and strive to make my work professional in quality.

✓ Wear appropriate clothing for specific volunteer assignments.

✓ Attend supplemental and advanced training whenever possible. Carry out my assignments in accordance with HSS training, and seek assistance from the Volunteer Coordinator or HSS staff member.

✓ Communicate any job-related problems, concerns, differences of opinion, conflicts, or suggestions only to Volunteer Coordinator or Executive Director.

✓ Adhere to sign-in and scheduling procedures.

✓ Notify the Volunteer Manager if I choose to discontinue my volunteer service with HSS.

✓ Give HSS permission to use photographs or video footage of my volunteer activities.

✓ I understand that The Humane Society of Sedona reserves the right to terminate my Volunteer status

as a result of any of the following:

❖ Any abuse or mistreatment of an animal

❖ Failure to comply with organizational policies, rules, and other regulations.

❖ Unsatisfactory attitude, work, or appearance.

❖ Any circumstances which, in the judgment of the Volunteer Coordinator or Executive Director, would make my continued service as a Volunteer contrary to the best interest of HSS.

WAIVER OF LIABILITY & AGREEMENT TO INDEMNIFY

✓ I hereby acknowledge that I desire to perform certain volunteer services for the Humane Society of Sedona(HSS), an Arizona non-profit organization.

✓ I further understand and acknowledge that certain risks may be associated with performing such volunteer services.

✓ In consideration of being permitted to perform services for the Humane Society of Sedona, I, for myself and my heirs and representatives, voluntarily and knowingly executes this document and expressly waives any and all rights, claims or causes of action including, without limitation, those involving bodily injury or property damage to me, or to my family or property while I am engaged directly or indirectly in performing the volunteer services, whether or not caused by the negligence of the Humane Society of Sedona, its officers, directors, agents or employees.

✓ In further consideration of being permitted to perform the volunteer services for the HSS, I hereby agree to indemnify, defend and hold the HSS, its officers, directors, agents an employee’s harmless from and against any and all liability, damage, loss, cost and expense incurred as a result of any claim, demand, or cause of action, brought against the HSS, its officers, directors, agents or employees, jointly or individually, for bodily injury or property damage suffered as a result of my negligent, reckless or willful act or omissions in the performance (or failure to perform) of the volunteer services.

✓ I have read and fully understand the contents of this Waiver of Liability and Agreement to Indemnify. This Waiver of Liability and Agreement to Indemnify shall continue in full force and effect until terminated in writing and in the event of such termination shall remain applicable to all matters occurring or first arising on or before the date of such termination regardless of such termination.

By checking the box below, I am indicating I have read and understand the above volunteer agreement conditions as well as the waiver of liability and agreement to indemnify; and I will fully comply with them.

I Agree

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