EPISODIC VOLUNTEER APPLICATION

Contact Information

Name:
Address (including city and postal code):
Home Phone: / Cell Phone: / Home Phone:
E-Mail Address*:
Preferred Contact: Phone q Email q / Access to a vehicle: Yes q No q

Emergency Contact Information

Name:
Address (including city and postal code):
Home Phone: / Cell Phone: / Work Phone:

Availability: During which hours are you available for volunteer assignments?

q Mornings / q Afternoons / q Evenings / q Weekends

Interests: Tell us in which areas you are interested in volunteering. Please note that not all opportunities are available at any given time.

¨  Special Event Marketing/ Communications: writing, editing skills, graphic arts, social media
¨  Special Events - other / ¨  Special Events – Cupcake Day
¨  Special Events - Bingo
¨  Special Events – Thrift Store
¨  Special Events – Coin Box Collection
¨  Special Events - Gala
¨  Fundraising Event Committee Member / ¨  Special Event Volunteer Captain (lead and direct volunteers on day of event)
¨  Awareness / Community Champion: Promotions, presentations / ¨  Administrative Support: Database management, research projects

References: At least one reference should be related to paid employment or volunteer work.

Name: / Phone:
Relationship:
Name: / Phone:
Relationship:

Do you have an up to date Police Check? Yes q No q

I agree to the following:

Ø  That I shall not appear for volunteer service under the influence of alcohol or illegal drugs.

Ø  That if I drive a vehicle to the volunteer site or during the course of my volunteer work, my personal vehicle insurance provides adequate insurance coverage.

Ø  That any photographs, videotapes, motion pictures or recordings taken of me may be used for publicity purposes for the Peterborough Humane Society.

Ø  The Peterborough Humane Society may send me email announcements of additional fundraising event volunteer opportunities and sign me up to receive the E-Newsletter.

o  I can choose to opt out of receiving such emails by checking this box: ☐ Opt out

Confidentiality Agreement

I pledge to uphold professional and ethical standards in respect to all information with which I come in contact with during my volunteer engagement with the Peterborough Humane Society. I pledge that all information will be held in the strictest confidence to ensure the anonymity and safety of all who are affiliated with the Peterborough Humane Society.

This applies to matters relating to:

·  Animals and/or donors associated with the Peterborough Humane Society

·  All business of the Society presently in force, or future projected affairs and activities under consideration by the Peterborough Humane Society.

Volunteer Release & Waiver of Liability

I waive and release any and all claims for myself, my heirs, my next of kin, executors, administrators and assigned representatives against the Peterborough Humane Society and any other sponsor or organization involved, from any and all liability for any loss, damage, expense, or injury including death or incapacity, however caused, including any claim or liability arising from the negligence of the Peterborough Humane Society and its agents (employees, students, volunteers) arising out of, or in the course of, my participation as a volunteer for which I choose to participate. This Release and Waiver extends to any and all claims, foreseen and unforeseen, known or unknown.

I agree to HOLD HARMLESS AND INDEMNIFY the Peterborough Humane Society from any and all liability for any property damage or personal injury to any third party resulting from my participation in volunteer activities with the Peterborough Humane Society.

I understand that as a volunteer with the Peterborough Humane Society I am NOT covered by the Ontario Workplace Safety and Insurance Act and that, as a result, I am not entitled to make any claims for compensation pursuant to the Ontario Workplace Safety and Insurance Act.

I agree not to make any statements, written or verbal, that defame, disparage or in any way criticize the personal or business reputation, practices, or conduct of the Peterborough Humane Society and its agents.

I confirm that I have read and understood this agreement prior to signing it, and I am aware that by signing this application I am waiving certain legal rights which I or my heirs, next of kin, executors, administrators, assigns and representatives may have against the Peterborough Humane Society.

I, ______, agree that the information provided on this form may be used to determine my suitability for this position, including the contacting of references indicated above.

______

Applicant Signature Date

______

Parent/Guardian Signature Date

Please note: A parent/guardian must also sign for volunteers under 18 years of age

Mail, fax or email form to Susan Dunkley, Manager of Development & Operations

385 Landsowne St. E Street, Peterborough, Ontario K9L 2A3

TEL: (705) 745-4722 ext 206 • FAX: (705) 745-9770 •

We respect your privacy. We collect your personal information in order to help identify and align suitable volunteers and opportunities. Only authorized Peterborough Humane Society staff and/or volunteers access this information. By providing an email address on this form you are giving consent to our use of email to contact you regarding volunteering.

Revised: Dec 28.2016

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