Name: 

Address: 

City:    State: 

Zip: 

Email address: 

Age of person performing Community Service: ** 

**Community Service people MUST be at least 16 years old.

Home phone: 

Work phone: 

Is it OK to contact you at work?  Yes          No

Days and times available to help:

Do you have any limitations (heavy lifting, limited walking, allergies, etc.)?

  Yes          No

If yes, please explain:

Physician: 

Phone #: 

In case of emergency notify:  (name of person) 

Relationship: 

Phone # (home): 

Phone # (work): 

Current Occupation: 

Employer Name: 

What is the reason for the community service?

  Community Service for School                 Community Service Court Ordered

   Group Community Service

What has been/is your experience with animals?

Have you been ever been convicted of a felony or misdemeanor?

  Yes            No

If yes, please explain:

 

PLEASE READ THE FOLLOWING SECTION CAREFULLY AND IF YOU UNDERSTAND AND AGREE TO THE TERMS, SELECT THE AGREE BUTTON BELOW AND SUBMIT YOUR APPLICATION.

As a community service person for the Cumberland Valley Animal Shelter, I hereby knowingly, freely and voluntarily waive my right or cause of action of any kind whatsoever against the Cumberland Valley Animal Shelter, its agents or employees for any injury, illness or disease I might contract or sustain while performing my community service. I also understand that I am not covered by workman's compensation.

I fully recognize and assume the possible dangers associated with the work of the Cumberland Valley Animal Shelter. I agree to notify staff immediately if I am bitten, scratched, otherwise injured or become ill during my volunteer service.

I will treat ALL ANIMALS with RESPECT and CARE and will follow all shelter rules.

I understand that any time I am working in a volunteer capacity with the Cumberland Valley Animal Shelter, I am acting as representative of the organization and will present myself and behave in an according manner.

I understand that I may be asked to leave the shelter immediately if I violate any of the shelter rules and that my position may be terminated.

THE CUMBERLAND VALLEY ANIMAL SHELTER MAKES NO REPRESENTATIONS CONCERNING ANY ANIMAL'S EXPOSURE TO RABIES OR OTHER COMMUNICABLE DISEASES.

I have read the Community Service Rules and Regulations and am prepared to be a help to shelter staff and work in the same capacity as an employee with CVAS.

   I agree to the above statements, terms and conditions on becoming a community service person with CVAS.                                

**Please note that by clicking the "I agree" button and then pushing submit, you are providing the electronic equivalent of your signature.