The Washington County Humane Society, Inc.

Volunteer Commitment Form

Name __________________________________________________     Date ________________

Address ________________________________________________________________________ 
 

City ___________________________________     State _________     Zip _________________

Home Phone ____________________________     Cell Phone ____________________________

Email __________________________________________________________________________

Emergency Contact ________________  Phone _______________  Relationship _____________

Please Check One:  q Adult      q Youth    Age (8 yrs-17 yrs) ____________

Community Service (Please check one of the following IF applicable):

 q Student   q Confirmation   q Court Ordered   q Other   Number of hours _________

I was referred to the WCHS by: ____________________________________________________

What is the reason you want to volunteer: ____________________________________________
 
________________________________________________________________________________

Do you understand you will be placed according to the need of the animals and to match your skills? 

 q Yes    q No

Please check the opportunities that interest you and/or match your skills:

Do you have limitations (i.e. allergies, heavy lifting, etc.):  q Yes    q No

      If yes, please explain ____________________________________________________________

Number of pets owned in the last 10 years:

     Dog _____   Cat _____   Bird _____   Rabbit _____   Other _____________________________

I am able to commit to ______ hours per month.

Are you willing to make a minimum 6 month commitment to volunteer?  q Yes    q No

ADULT VOLUNTEER WAIVER

I am agreeing to act as a volunteer for WCHS.  I acknowledge and agree that activities performed strictly on a voluntary basis, without pay, compensation or benefits.  I agree to comply with the rules and regulations established by WCHS and failure to do so may result in my immediate removal as a volunteer. 
I am aware of the nature of the activities to be performed as a volunteer and I recognize and understand there are certain risks inherent in handling animals and I accept those risks.  I agree that all volunteer activities are performed at my own risk.  I understand if an accident/injury occurs, no matter how minor, I will complete a Volunteer Injury Report form and seek any necessary medical attention using my own medical insurance.  On behalf of myself and my respective heirs and personal representative, I agree to indemnify and hold harmless WCHS, its officers, directors, employees, agents and volunteers from and against any loss, damage, claims, liability, costs and expenses of any nature whatsoever, including but not limited to, attorney’s fees and disbursements arising from or occasioned by my activities as a volunteer for WCHS. I agree that WCHS may use my image for WCHS displays, educational programs and/or other public relations, and I hereby release any such images/photographs for use in its programs, publications and purposes. 

I have read the above waiver and state that I understand it and that I am voluntarily signing it without any inducement or representation from any member of the WCHS staff. 

________________________________________________
Signature  

________________________________________________
Signature of Volunteer Coordinator

____________________
Date

____________________
Date

MINOR VOLUNTEER WAIVER

(To be completed by a parent/guardian of volunteers under 18)

I am the parent/guardian of________________________________________, a minor volunteer, under eighteen (18) years of age, hereby consent and authorize______________________ to act as a volunteer for WCHS.  I acknowledge and agree that activities performed by my child as a volunteer will be performed strictly on a voluntary basis, without any pay, compensation, or benefits.  I agree to comply with the rules and regulations established by WCHS and failure to do so may result in the immediate removal of my child as a volunteer. 

I am aware of the nature of the activities to be performed by my child as a volunteer and I recognize and understand there are risks inherent in handling animals and I accept those risks.  I agree that all volunteer activities performed by my child will be at the child’s risk and I assume full responsibility.  Therefore, I understand that if an accident/injury occurs, no matter how minor, my child will complete a Volunteer Injury Report form and seek any necessary medical attention, using my own medical insurance.  On behalf of myself, the child, and our respective heirs and personal representative, I agree to indemnify and hold harmless WCHS, its officers, directors, employees, agents, and volunteers from and against any and all loss, damage, claims, liability, costs and expenses of any nature whatsoever, including but not limited to attorney’s fees and disbursements, arising from or occasioned by my child’s activities as a volunteer for WCHS.  I agree that WCHS may use my child’s image for WCHS displays, educational programs and/or public relations, and I hereby release any such images/photographs for use in its programs, publications and purposes.

I have read the above waiver and state that I understand it and I am voluntarily signing it without any inducement or representation from any member of the WCHS staff. 
 

________________________________________________
Signature of Parent/Guardian

________________________________________________
Signature of Minor Volunteer                                      

________________________________________________
Signature of Volunteer Coordinator                                                 

____________________
Date

____________________
Date

____________________
Date

If there is an opening for the position for which you are applying, you will be

contacted to attend an orientation.  Volunteers will be placed according to the

need of the animals and to match your skills.  Thank you for your time.

Any questions, please contact Kerry Kasten, Volunteer Coordinator, at

(262) 677-0731 or volunteer@washingtoncountyhumane.org. 

Return completed form to:
The Washington County Humane Society
Attn: Kerry
3650 State Road 60
Slinger, WI  53086