BLUE RIDGE ASSISTANCE DOGS

Volunteer Application

Date: _____________________

Name: _________________________________________________

Address: _______________________________________________

__________________________________________________

E-MailAddress: __________________________________________

Home Phone: ____________________

Work Phone: ____________________
May we call you at work: Yes No

Please circle your age group: 10-17 18-30 31-50 51-65 66-80 80+

Please circle the last type of school attended:

Junior High High School College

How did you learn about Blue Ridge Assistance Dogs?

Please indicate below the days of the week and the hours you are available for volunteer work:

AM PM

From To From To

Monday ----- -----

Tuesday ----- -----

Wednesday ----- -----

Thursday ----- -----

Friday ----- -----

Saturday ----- -----

Sunday ----- -----

Any additional comments about your schedule?

When can you start volunteer work?

Please indicate the type of volunteer work you are interested in:

How will your work with Blue Ridge Assistance Dogs be of benefit to you?

How will your work with Blue Ridge Assistance Dogs be of benefit to our program?

Do you have any special skills or interests?

Do you work best when you …..

______ initiate and follow-through by yourself (after sufficient

training), or …..

______ receive ongoing direction?

Please list your previous volunteer work experience.

Place Type of work

___________________ ________________________________

___________________ ________________________________

___________________ ________________________________

If you are employed, please indicate your employer’s name and address.

Place Type of work

__________________ _______________________________

__________________ _______________________________

__________________ _______________________________

Please list someone we can call in case of an emergency.

Name: ____________________________________________

Address: ____________________________________________
____________________________________________
____________________________________________
Home Phone: _________________________________________
Work Phone: _________________________________________

Do you have any medical conditions which may affect your work or of which we should be made aware?

VOLUNTEER APPLICANT AGREEMENT

In anticipation that you will be accepted into Blue Ridge Assistance Dogs’ volunteer program, please read and sign the agreement below:

I declare that the above information is accurate.

I indemnify and hold Blue Ridge Assistance Dogs (BRAD) harmless from and against all claims, losses, liabilities, and damage to person or property, government charges or fines and attorney fees arising out of the acts or omissions of BRAD, including but not limited to interactions with staff, visitors, or dogs.

I authorize BRAD to seek emergency medical treatment in case of accident, injury, or illness.

I understand that if I am injured while acting as an unpaid member of the volunteer staff that I will NOT be covered by Virginia State Worker’s Compensation Law.

______________________________________________________

Signature Date

FOLLOWING FOR OFFICE USE ONLY

Date:

Applying for job of:

Date called to set up interview:

Interview:

Date of interview:

Assigned job: Not assigned job:

Starting date:

Weekly schedule:

Comments:

Please mail to:

Blue Ridge Assistance Dogs
P.O. Box 229
Manassas, Virginia 20108