(Please Print)

Name____________________________

Address_____________________________________________________________
(Street) (City) (State)

Phone__________________ Date of Birth___________ SS#_________________

Driver License_____________________

Emergency contact_________________________ Phone number_________________

Education: (Circle last year completed)
Highschool 1 2 3 4 College 1 2 3 4 Graduate 1 2 3 4

Are you presently in school?_____ If yes, name of school ___________________

What is your course of study?_____________________________

When do you plan to graduate?____________________________

Are you presently employed?_____ If yes, please state your work schedule__________
Name and address of employer____________________________________________
Phone___________________
Present occupation____________________
Previous work experience________________________________________________
Describe present and previous volunteer jobs_________________________________
_____________________________________________________________________

Do you have pets at the time?_____ How Many?___ Cats___ Dogs___ Other___
Are they: Spayed/Neutered____ Inside/Outside______________________________
Confined to property____ How?_________________________________________
Name of vet/clinic you use________________________________________________

Describe any previous experience working with animals___________________________
_______________________________________________________________________

Why are you interested in becoming a HSSI volunteer_____________________________
________________________________________________________________________

Please list any special skills, training, interest, or hobbies___________________________
________________________________________________________________________

How did you hear about HSSI volunteer program? (Please circle your answer)
Newspaper Friend Radio Television HSSI Newsletter

Are you available regularly each week?____

Please circle areas of interest: Inhouse Socialization Office/clerical Newsletter
Education Foster care Public relations Fund raising

Please indicate the times which you would be available for work:
Monday_______ Tuesday_______ Wednesday________ Thursday________
Friday________ Saturday______ Sunday_________ Anytime__________

We would be interested in any further information you may wish to offer______________
________________________________________________________________________
________________________________________________________________________

I give my permission to the Humane Society of Southern Illinois to verify any of the information given.

___________________________
(Volunteer signature)

____________________
(Date)