Your Name (required)

Date of Birth

Address (required)

City, State, Zip (required)

Home Phone (required)

Cell Phone

Your Email (required)

Emergency Contact Name (required)

Contact Relation:

Contact Phone: (required)

Your Occupation:

May we contact you at work?
 Yes No

Number & type of pets you own:

Are your pets spayed / neutered?
 Yes No

If no, do you plan to breed them?
 Yes No

My regular Veterinarian is:

Do you have particular talents you are willing to volunteer to provide for LCHS?
 Construction Accounting Public Speaking Veterinary training (RVT, DVM) Legal Public relations /. advertsing Dog Training

Other Talent than above to volunteer?

I'd like to help LCHS with these efforts:
 Adoption Events Advocacy Facebook Fostering Fund raising Humane Education Newsletter Outreach Photography Publicity Spay/Neuter Transports

Other than your own pets, do you have experience working with animals
---YesNo

If yes, please describe

Have you ever been accused of or convicted of animal cruelty (required)?
---YesNo

Other than a traffic violation, have you been convicted of a criminal offense (required)?
---YesNo

If yes, please describe:

Do you have a valid driver’s license (required)?
---YesNo

State licensed in:

Please provide DL#

Would you be willing to transport animals as part of your volunteer work?
---YesNo

If yes, is the car you’d be driving covered by liability insurance?
---YesNo

Name of Insurance Company

Have you ever pled guilty to a traffic violation (required)?
---YesNo

Do you have any allergies, physical disabilities, or other limitations that may require accommodation or may restrict your volunteer activity?
 Yes No

If yes, please explain:

Why do you want to volunteer for LCHS?

If a current member /volunteer recommended you to work with LCHS, please give their name so that we can thank them.

I would like to receive information about planned giving (wills).
 Yes No

By clicking on the Send Button:
1. I am electronically affixing my signature to this application.
2. I give LCHS permission to verify any information given on this application; and
3. I read, understand, and am electronically affixing my signature to the Volunteer Code of Ethics and Agreement below.

Volunteer Ethics and Agreement states that the Volunteer shall:
1. Expect from LCHS appropriate training and support to perform volunteer duties.
2. Bring credit to LCHS, and any fund raising involved, by their public demeanor.
3. Put the LCHS mission above personal gain or aggrandizement.
4. Avoid even the appearance of any criminal offense or misconduct, especially in reference to the treatment of animals.
5. Donate my services to LCHS without thought of potential compensation, other remuneration or benefits, or future employment.
6. Assure all communication with the public conforms to the LCHS vision, mission, and values.
7. Refrain from making public statements on behalf of LCHS unless by way of a LCHS approved public communication.
8. Demonstrate the utmost compassion and care with animals, and never strike an animal, or handle or treat an animal in such a way that may be construed as rough or abusive.
9. Hold LCHS harmless for any injury(s) I might sustain, specifically including the handling of animals, during the course of my volunteer activities.
10. Keep safety at the forefront of all volunteer acitivities.
11. Hold myself accountable for the volunteer commitments I undertake, and communicate to LCHS if I am unable to perform them or no longer wish to volunteer with LCHS.
12. Recognize that LCHS may terminate my services as a Volunteer at any time.
13. Follow al LCHS rules, policies, and procedures, as presented to me.