Volunteer Information

Please PRINT clearly

Name________________________________________ Date______________________

Address_____________________________________City_________________________

Physical address if different from above_______________________________________

Phone: Home_________________ Work___________________ Cell_______________

e-mail_________________________________ Date of birth_______________________

**Emergency contact name & number______________________________________

_______________________________________________________________________

Are you currently enrolled in school? Yes No If yes, what school?__________________

Previous volunteer experience ________________________________________________________________________

________________________________________________________________________

Do you have any experience working with animals? Describe________________________________________________________________

_______________________________________________________________________

Do you have pets? Yes No Are they spayed or neutered? Yes No

Are you currently employed? Yes No If yes, may we contact you at work? Yes No

Employer_____________________________ Brief description of what you do at work

________________________________________________________________________

List any special skills, training, hobbies ________________________________________________________________________

________________________________________________________________________

Please check the volunteer opportunities in which you would be interested:

___ cat grooming/socializing ___ photography ___ gardening/yard work

___ dog walking ___ computer wizard ___ marketing/PR

___ special events ___ foster parent ___ fund raising

___ general cleaning ___other ideas ________________________

Please indicate days and times you are available:

Wed:________ Thurs:________ Fri:________ Sat:________

Please list two references that are not family members:

________________________________________________________________________

Name Relationship Phone

________________________________________________________________________

Name Relationship Phone

My signature gives permission to the Springfield Humane Society to verify all information given herein.

Signed________________________________________________Date______________

Revised 1-10