CIK9 Volunteer Application

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State

Zip Code

Phone Number *

Area Code Phone Number

Email *

example@example.com

Previous Volunteer Experience *

List organizations, dates, and duties

Why would like to volunteer with CIK9? Special Skills? *

What days/times are you available to assist? *

In case of emergency, I authorize Central Indiana K9 Association to arrange for emergency medical treatment after notifying or attempting to notify individuals listed below.

Emergency Contact 1 *

First Name Last Name

Emergency Contact 1 *

Area Code Phone Number

Emergency Contact 2 *

First Name Last Name

Emergency Contact 2 *

Area Code Phone Number

I confirm that I am 16 years of age or older. *

Yes No

I agree that CIK9 may photograph me while participating in volunteer activities, and I hereby release any such photographs to CIK9 for use in its programs, publications, and purposes.

I agree I disagree

In consideration of CIK9 accepting my application for participation in CIK9 programs, I agree to release and hold harmless, CIK9 from and against any and all loss, damage, claims, liability, costs, and expenses, of any nature whatsoever, including without limitation, attorney's fees, and disbursements arising from, or occasioned by my participation in CIK9's programs. I understand there are certain risks inherent as a volunteer and I accept those risks. I understand if an accident or injury should occur, that I will seek any necessary medical attention utilizing my own medical insurance and I will be responsible for any resulting medical bills. *

I agree I disagree

Please make your signature below. Date submitted will serve as date signed. *

Clear

You will receive an email copy for your records.