Volunteer Application

2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Home Phone
12. Cell Phone
14. Date of Birth
    Date of Birth
15. Driver's License Number
17. Occupation
19. Emergency Contact Name
20. Relationship
22. Emergency Contact Address
24. Emergency Contact Home Phone
25. Emergency Contact Cell Phone
27. Please list two personal or business references (that know of your animal experience).
29. Reference #1 Name
30. Reference #1 Number
32. Reference #2 Name
33. Reference #2 Number
35. Louisa County Animal Shelter requires that Tetanus and other vaccines be current prior to beginning volunteer activities.
37. Date of Last Tetanus Vaccination
    Date of Last Tetanus Vaccination
39. Why are you interested in becoming a volunteer?
41. Do you have any questions about LCAS?
43. What are your thoughts about spaying and neutering pets?
45. What are your thoughts about euthanasia?
47. Do you understand some animals are euthanized?
49. Do you have any animals you are responsible for? Please list all including species, breed, age.
51. Do you have any allergies or physical conditions that might affect your volunteer work? Please explain.
53. Are you affiliated with any animal welfare organizations? If so, please describe.
55. Have you ever been arrested or convicted of a crime?

    1. Yes
    2. No
56. Note: An arrest or conviction will not necessarily disqualify you for volunteer activities. The circumstances of the conviction will be considered based upon the nature and duties of the requested volunteer activities.
57. If yes, please describe.
59. Please list any skills, talents, experience, or resources that you have that you think would benefit LCAS.
61. Please list days and times you wish to volunteer.
63. Please list any volunteer jobs you are interested in.
67. Louisa County reserves the right to process a criminal records check if it is deemed necessary. We must protect animals in our care.
69. All positions require an interview, orientation, and training.
71. We value your privacy and will not share your information.
73. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
75. Date
    Date
77. Electronic Signature
81. To comply with State Code 3.2-6548:
83. I
84. Name
85. swear or affirm that I have never been convicted of animal cruelty, or animal neglect, or animal abandonment.
87. Full Name
89. Address
91. City
92. State
93. Zip Code
95. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
97. Date
    Date
99. Electronic Signature
103. Media Release
105. During my volunteer activities with Louisa County Animal Shelter, I understand my photo may be taken during various duties, events, or projects. By signing below, I hereby grant Louisa County to use my photograph(s) and/or video(s) in any and all publications or on the World Wide Web.
107. Full Name
109. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
111. Date
     Date
113. Electronic Signature
117. Volunteer Agreement
119. In consideration of this opportunity to volunteer for the Louisa County Animal Shelter, I
120. Name
122. agree to the following terms and conditions, intending to be legally bonding to them: I will abide by the mission, rules, regulations, policies and programs. I will provide humane treatment to all animals. I will not engage in any unsafe, illegal, or unethical activities while serving as a volunteer. I agree to hold Louisa County harmless and enter into an additional waiver of liability and indemnification.
124. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
126. Date
     Date
128. Electronic Signature
132. Release of Liability and Indemnification
134. I recognize that while performing my services in a voluntary capacity handling animals, there exists a risk of injury, including physical harm to me. On behalf of myself, my heirs and personal representatives, I hereby release, discharge, indemnify and hold the Louisa County Animal Shelter, the County of Louisa, agents, servants and employees from any and all claims, causes of action or demands of any nature or cause connected with my volunteer services based on damages or injuries which may be incurred or sustained by me in any way connected with my volunteer work. Such damages or injuries might include, but are not limited to animal bites, scratches, accidents, injuries, or personal property damage. I acknowledge that I have read and fully understand the terms and conditions of the foregoing Release of Liability and Indemnification.
136. Full Name
138. Address
140. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
142. Date
     Date
144. Electronic Signature
Leave This Blank:


146. 1. Receive an email copy of this form.
147. Email address

     This field is not part of the form submission.

148. Submit

* indicates a required field