Volunteer Application

Today’s Date:______________________

Name:____________________________________________________________

Address:__________________________________________________________

Birthdate:___________ (volunteers MUST be 16 years of age)

Email:____________________________

Home Phone:______________________ Cell Phone:________________________

Emergency Contact:_________________ Phone:____________________________

Location Preference:

□ Greenfield  □ Leverett  □ No preference

Besides fulfilling your love for animals, what else do you hope to get out of your volunteer experience at the Dakin Pioneer Valley Humane Society?

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Please describe any special skills or animal-related experience you may have:

___________________________________________________________________________

___________________________________________________________________________

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Check any volunteer opportunities that interest you:

�     Animal Caregiver        �     Enrichment Specialist       �     Foster Parent     

�     Closing Helper            �     Pet Taxi Driver       �     Pet Visitation Volunteer

�     Office Helper              �     Data Entry Volunteer

�     Other Opportunities (i.e. Feral Spay Sunday, Special Events, Maintenance, Graphic Design, Community Outreach)

 Which day(s) can you volunteer?

     Monday    Tuesday    Wednesday  Thursday   Friday   Saturday   Sunday     

What time are you available: 

�  early mornings     �  late mornings     � afternoons    � Special Events                             

Are you volunteering for a class?

Course:______________________________

Is your service court mandated?  Yes / No

Please read the following statement and sign in the space provided.

As a volunteer with the Dakin Pioneer Valley Humane Society, I understand the risks involved in working near or with any animal, including the risk of personal injury.  On behalf of myself, my heirs, personal representatives and executors, I hereby release, discharge, indemnify and hold harmless The Dakin Pioneer Valley Humane Society, its agents, servants and employees from any and all claims, causes of action, or demands, of any nature or cause, including costs and attorney’s fees incurred by the Dakin Pioneer Valley Humane Society, in connection with the same, based on damages or injuries which may be incurred, or sustained by me in any way connected with my services for the Dakin Pioneer Valley Humane Society, including, but not limited to, animal bites, accidents or injuries.

_______________________________________Signature of Volunteer (Parent/Guardian if less than 18 years old)

____________________________________________Date

Mail your completed application to:

Dakin Pioneer Valley Humane Society, Volunteer Application, 163 Montague  Road, Leverett, MA  01054

 Questions?  Call or email:

Eden Schurlknight- (413) 548-9898 x 3  or eschurlknight@dpvhs.org

THANK YOU!