Adult Volunteer Application | Fox Valley Humane Association

First Name: *

Middle Initial: *

Last Name: *

Street Address: *

City *

State: *

Zip Code: *

Email Address (this will be our main form of communication with you): *

Phone number: *

Date of Birth: *

Drivers License Number: *

Pets in your household, if any:

Occupation (Adult Only): *

Employer (Adult Only): *

Emergency Contact: Name and Phone (Adult Only) *

Personal Reference 1: Name and Phone (Adult Only) *

Personal Reference 2: Name and Phone (Adult Only) *

Do you have any physical or medical limitations which may limit your participation as a volunteer?: *

Are you able to volunteer for at 4 hours each month? *

Yes

No

Do you have your own transportation?: *

Yes

No

Do you have an insured truck or van?: *

Yes

No

Have you ever been convicted of a crime? If yes, give date and explain nature of conviction: *

Have you ever consulted with a professional person for psychological disorders concerning animals?: *

Why do you want to become an FVHA volunteer?:

List any additional information or concerns:

Please select the Shelter Operations tasks you have an interest in:

Volunteer Insurance Waiver - By checking this box and typing my name in the signature line below, I am electronically signing this agreement:

I understand that the Fox Valley Humane Association requires the assistance of volunteers in conducting its various programs. It is my desire to further the work of the Association by performing services as a volunteer. I undertake to perform these services without compensation, and in performing my services, I acknowledge that I am not acting as an employee of the Association. I will not hold the Association liable for any personal or property damage I may incur while performing volunteer services. I agree to conform to the Association’s policies and procedures while volunteering. I agree to hold all information shared with me while volunteering at FVHA in strict confidence.

Please check the box: *

Yes, I understand.

Confidentiality Agreement - By checking this box and typing my name in the signature line below, I am electronically signing this agreement:

This confidentiality agreement is required for the protection of Fox Valley Humane Association (FVHA) and in recognition that employees/volunteers/board members of FVHA may either acquire or observe documents, or overhear conversation, or information that is private and confidential in nature. Accordingly the undersigned employee/volunteer/board member agrees that if he or she comes into possession of either written or oral information of any kind about FVHA, its employees/volunteers/board members, or clients as the result of employment/volunteer/board work with FVHA, the undersigned agrees to keep all such information confidential and not disclose or publish this information to any person unless expressly permitted in writing by FVHA Executive Director or President of the Board of Directors. It is acknowledged that this Agreement is not only for the protection of FVHA and its clients regarding their confidential information but the Agreement is also a reminder to the undersigned that inappropriate disclosure of such confidential information by the undersigned could expose the undersigned to liability or claims if the disclosure of such information cause either monetary damage or other irreparable harm to FVHA or its clients.

Please check the box: *

Yes, I agree.

By typing my name in this signature line, I am electronically signing the above Insurance Waiver and Confidentiality Agreement: *

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