Volunteer Application and Waiver of Liability

APPLICANT

First Name: *

Last Name: *

Street Address: *

City: *

State: *

Zip Code: *

Home Phone:

Cell Phone: *

Work Phone:

E-Mail Address: *

Full Name

Do you have a Driver's License? * Yes No

Note: At times volunteers help by transporting animals. Per our insurance, we need the driver's license information of a person helping with transportation.

State: *

Driver's License Number:

Birth Day *

Birth Month *

Birth Year *

Date of Birth

Today's Date

Age *

I understand volunteers under 17 years of age will require an adult (18 or over) to be present when volunteering. * Agree Disagree

I understand volunteers under 18 years of age will require an Electronic Signature from Parent or Guardian at the bottom of this form. * Agree Disagree

ADDITIONAL INFORMATION

Other:

Are you on Facebook? * Yes No

Have you volunteered for any other animal organizations? * Yes No

If yes, who?

What type of Volunteer Work are you interested in? (You can choose any (no limit) from our volunteer opportunity list or tell us what talent you possess that you would like to incorporate with our group (list below)): Hands-on help at the Rescue Center (mostly adult dogs, walking/cleaning/feeding) Hands-on help at the Adoption Center (mostly puppies, cleaning/feeding/playing) Hands-on help Petco-Middletown, KY - (cats, cleaning their condo/feeding/snuggling) Hands-on help Petco-Jeffersonville, IN - (cats, cleaning their condo/feeding/snuggling) Fostering (dogs or cats) Transport (mostly taking puppies/dogs between our Centers and the vet (Hopewell Animal Clinic)/Petco in Middletown, KY)) Work day with a group (ie: a BETA Club, a scout troop, etc), a single work day to benefit the rescue Other (please list below)

Additional Talents:

Explain any experience with caring or working with animals you feel may benefit our organization.

How much time (hours, days etc.) per month would you like to devote to volunteer work with Adopt Me! Bluegrass Pet Rescue?

Do you have any conditions or limitations that would prevent you from specific volunteer activities that we should be aware of? * Yes No

If yes, please list any condition(s) you wish to disclose.

EMERGENCY CONTACT INFORMATION (Primary)

Please enter the Information below for an Emergency Contact. If desired, a second Emergency Contact maybe listed.

First Name: *

Last Name: *

Same Address as Applicant:

Street Address: *

City: *

State: *

Zip Code: *

Phone: *

E-Mail Address: *

EMERGENCY CONTACT INFORMATION (Secondary)

First Name:

Last Name:

Same Address as Applicant:

Street Address:

City:

State:

Zip Code:

Phone:

E-Mail Address:

WAIVER OF LIABILITY

I understand as a volunteer with Adopt Me! Bluegrass Pet Rescue, I may come in contact with animals with unknown histories. * Agree Disagree

I understand these animals may have undiagnosed diseases, conditions, and/or behavioral problems that are unknown to Adopt Me! Bluegrass Pet Rescue. * Agree Disagree

I am willing to undertake the risks of working with animals of unknown history and/or temperament. * Agree Disagree

I do not hold Adopt Me! Bluegrass Pet Rescue, its Board or volunteers responsible for any injuries or illnesses that I may encounter while volunteering. * Agree Disagree

I understand the risks involved and willingly participate in volunteer activities on behalf of Adopt Me! Bluegrass Pet Rescue. * Agree Disagree

SIGNATURE

Applicant Signature: * (Please type your Full Name in the Box below) *

* Agreement: By entering my name in the box above, I confirm that to the best of my knowledge, all information furnished in this application is true and correct.