Volunteer Application

Page 1

Applicant Information

First Name

Middle Name

Last Name

Birthdate (mm/dd/yyyy)

Gender

Contact Information

Preferred Communication Type

Address

City

State/Province

Zip/Postal Code

Preferred Email

Personal Email

Work Email

Alternate Email

Preferred Phone

Home Phone

Work Phone

Mobile Phone

Other Phone

General Information

If Employed, Name of Employer

If Student, Name of School

Any Health or Physical Restrictions?

Previous Volunteer Experience

Contact in Case of Emergency

Emergency Contact Phone #

Emergency Contact Cell #

Days and Hours Available

Page 2

Tell Us about You

I am interested in volunteering in the following areas or capacities:

Why do you want to volunteer at Custom Canines?

What types of recognition do you prefer/not prefer?

How did you hear about Custom Canines volunteer opportunities?

Driver's Information

Driver's License

State

What types of vehicles are you licensed to drive?

State ID

State

Within the last 5 years have you been convicted of any crime? Please explain:

Page 3

By signing this application, I agree to treat all information I may hear, see,

read or otherwise acquire as highly confidential and I will not reveal or

discuss this information outside my official duties at

Custom Canines Service Dog Academy.

Additionally, I understand that by signing this application, I agree to

release Custom Canines Service Dog Academy of any and all

liability for any incidents, accidents, injuries, or falls that may occur

during the duration of time that I volunteer for this organization. I am

personally responsible for my own personal health insurance and coverage

to ensure proper treatment may be available if I am injured during my volunteer activities.

Applicant Signature

Please enter your full name

Date