Volunteer Application Name First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell Phone(Required)Email(Required) Emergency Contact Name(Required) Emergency Contact Phone Do you have a Facebook Account?(Required) Yes No Every volunteer is important to our organization. These are some of the volunteer opportunities available: Check all that you would be interested in: Adoption Follow-Up (Call recent adopters to ensure a smooth transition) Fundraising/Events Volunteer – Assist with set up/breakdown and participate in the event/fundraiser. Bake/Craft Sales – Provide goodies for bake sales, make crafts to sell at events and or sitting at the event table Cat Room Volunteer – Assist with cleaning and disinfecting cat rooms, clean litter boxes, change furniture coverings, clean/disinfect floors, walls and counters. Kennel Volunteer – Assist with cleaning and disinfecting dog kennels as directed by staff. Maintenance/Groundskeeper Volunteer – Clearing snow in winter, mowing grass in summer, general upkeep Transportation of Animals (to vet appointments, adoption events, etc.) Valid driver’s license and proof of insurance required Grant Writing Video/Photography for dog/cat bios Social Media/Public Relations Volunteer – Help promote PCHS events, write articles for website and newsletter. Animal Foster Home for Dogs and Puppies Animal Foster Home for Cats and Kittens Select AllPlease list any special skills not mentioned above Volunteer Acknowledgement and Waiver of Liability/ConfidentialityPlease read, check, sign, and date below. In signing, you are waiving certain rights and you are urged to do so only if you are financially able to be responsible for your injuries or illnesses.Please agree to all of the following by checking each box. I agree to conduct myself in a courteous and professional manner as a volunteer and as a representative of the Pike County Humane Society Animals behave in unpredictable ways when injured, ill, frightened, or agitated. This can be especially true for animals being housed in a shelter environment and subject to numerous strangers. For my safety and that of the animals, I agree to the follow Pike County Humane Society’s instructions for safe animal handling. I further acknowledge that I am aware of the risk of physical injury that can result from feral or domesticated animals, and I have assumed all risks of being in proximity to animals. Volunteers are strongly urged to carry adequate health insurance coverage for any illness or injury that may result from proximity to animals. For those who do not wish to assume these risks or who do not have insurance, Pike County Humane Society welcomes your interest in volunteering for activities that will not bring you in close proximity to animals. I grant permission to add my email address to Pike County Humane Society’s newsletter. You will have the option to unsubscribe to this newsletter at any time. I irrevocably authorize Pike County Humane Society to copy, exhibit, publish or distribute my likeness in any photograph in any and all of its publications, written or electronic, including but not limited to websites and social media. I further acknowledge that I will abide and follow all rules and procedures set forth by Pike County Humane Society. I authorize the Pike County Humane Society to contact the emergency contact on this application and to seek emergency medical care in case of accident, injury or illness I agree that my services are provided on a volunteer basis without pay or compensation of any kind I understand that before I can volunteer, I must attend an orientation. A PCHS representative will be in contact regarding the next available orientation. I am aware of my obligation to respect confidentiality. I know that I am obliged to maintain the absolute confidentiality of personal, confidential and proprietary information. I further agree to not disclose such information even after my participation with Pike County Humane Society has ceased. I further agree to comply with all privacy laws and regulations, which apply to the collection, use and disclosure of personal information. I AGREE THAT ON BEHALF OF MYSELF, MY HEIRS, PERSONAL REPRESENTATIVES AND EXECUTORS, TO RELEASE, DISCHARGE, INDEMNIFY AND HOLD HARMLESS THE PIKE COUNTY HUMANE SOCIETY, ITS AGENTS, EMPLOYEES, VOLUNTEERS, DIRECTORS AND BOARD OF DIRECTORS FROM ANY AND ALL CLAIMS, CAUSES OF ACTION, OR DEMANDS OF ANY NATURE OF CAUSE, INCLUDING COSTS AND ATTORNEY FEES INCURRED BY THE PIKE COUNTY 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 PIKE COUNTY HUMANE SOCIETY INCLUDING BUT NOT LIMITED TO ANIMAL BITES, ACCIDENTS, INJURIES, ETC. Volunteer Signature(Required) Reset signature Signature locked. Reset to sign again Are you 18 years or older?(Required) Yes No Parent/Guardian Signature(Required if volunteer is under 18 years of age) Reset signature Signature locked. Reset to sign again CommentsThis field is for validation purposes and should be left unchanged.