Name: 

Address: 

City:  State: 

Zip: 

Birth date
**YOU MUST BE AT LEAST 16 YEARS OLD TO PERFORM COMMUNITY SERVICE WITH CVAS

Your email address:

How many hours do you need to complete?

Home phone (including area code): 

Work phone (including area code): 

Is it OK to contact you at work?  Yes No

Days and times available to help: Days and times available help

Do you have any limitations (heavy lifting, limited walking, allergies, etc.)? Yes No

If yes, please explain:

Physician: 

Physician phone number (including area code): 

In case of emergency notify:  (name of person) 

Relationship: 

Emergency Contact Home Phone (including area code): 

Emergency Contact Work Phone (including area code): 

Current Occupation: 

Employer Name: 

What is the reason for your community service. Please be SPECIFIC here when you describe the reasons for needing community service. In order to get credit for graduation or court-ordered service, please explain thoroughly what the community service is for.)

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.

While performing community service 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 I am volunteering. 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 performing community service for 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 AND UNDERSTAND THE COMMUNITY SERVICE RULES AND REGULATIONS AND AM WILLING TO ABIDE BY THEM TO COMPLETE THE HOURS I NEED.

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

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

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