Thank you for your interest in volunteering. The ASPCA Response Team is a group of specially trained staff members and volunteers who respond to man-made and natural disasters throughout the country. Please complete the following information and return your application via fax or email Gina Manke, Responder Manager, Email: gina.manke@aspca.org, Fax: (866) 315-7619 Personal Information Full Name: Address: Last First M.I. Street Address Apartment/Unit # City State ZIP Code Home Phone: ( ) Alternate Phone: ( ) E-mail Address: Drivers License Number or Government ID: Birth Date: Required Certifications **The following online FEMA courses are required and can be found at http://training.fema.gov. Please include scanned copies of your certifications with your application, or email the links to your certificates to gina.manke@aspca.org Course FEMA IS-100.A Introduction to the Incident Command System, I-100 FEMA IS-200.A ICS for Single Resources and Initial Action Incidents FEMA IS-700.A A National Incident Management System (NIMS), An Introduction FEMA IS-800.B National Response Framework, An Introduction Date of Completion Additional Certifications **List any additional emergency response or animal rescue certifications you have. Please include scanned copies of certifications with your application** Certification Date obtained Valid until Use additional page if more room required 1
Vaccine History **Please include copies of your vaccine documentation with your application** Hep A/B Date: Rabies Date: Tetanus Date: Other ( ) Date: Emergency Contact Information Full Name: Address: Last First M.I. Street Address Apartment/Unit # City State ZIP Code Primary Phone: ( ) Alternate Phone: ( ) Relationship: Training and Experience **List any additional emergency response or animal rescue training and experience you have. Exp 2
Volunteer Disclaimer I understand that, based on the completion of this volunteer application and disclaimer form, the screening process, and any available volunteer training and orientation, The Field Investigations and Response department reserves the right to determine who will be approved as a volunteer. During an event, volunteers will be deployed at the discretion of the Field Investigations and Response Team. I understand that volunteering with the ASPCA Response Team will require travel to an event, and will require my being away from my job and home for a pre-determined length of time. I also understand that while the ASPCA will cover the costs associated with travel, meals and lodging during the response, I will not be otherwise compensated for my time. I understand that I am not obligated, if called upon, to participate in any response. While working with the ASPCA at a response, I am expected to abide by the organization s code of professional conduct, always modeling the highest professional standards. I agree to abide by the authority of the ASPCA and to follow all reasonable instructions while participating under their leadership. By signing below, you agree that you have read and understand the above disclaimer, and that all information you have provided in the application is true and accurate. Signature: Printed name: Date: 3
Volunteer Agreement and Release of Liability On this day of, 20, I hereby acknowledge that I have voluntarily applied to assist the ASPCA (without compensation) with in a disaster and/or cruelty investigation situation to which the ASPCA is responding. I AM AWARE THAT WORKING IN A DISASTER and/or CRUELTY INVESTIGATION SITUATION MAY BE HAZARDOUS, AND I AM VOLUNTARILY PARTICIPATING IN THIS ACTIVITY WITH FULL KNOWLEDGE OF THE NATURE AND DANGER INVOLVED AND HEREBY AGREE TO ACCEPT ANY AND ALL RISKS OF INJURY OR DEATH. I recognize that I am not entitled to medical disability, life insurance coverage or any other compensation from the ASPCA and that I am required to carry my own medical and personal injury insurance (including, if applicable, veterinary professional malpractice insurance). I understand that I may at any time with or without cause be removed from my volunteer position at the sole discretion of the ASPCA. While I acknowledge that I will not receive any compensation as a volunteer, the ASPCA will pay for the following if I submit the appropriate receipts after the disaster and/or cruelty investigation has ended: [If none are not applicable, write N/A here] Transportation to disaster and/or cruelty investigation via the ASPCA s travel agent or via your personally owned vehicle with a standard mileage reimbursement rate of $.55 per mile. Meal stipend up to $_* per day. (*Varies based on location and operation) Lodging will be arranged for, and covered by, the ASPCA. As lawful consideration for being permitted by the ASPCA to assist in a disaster and/or cruelty investigation situation, I hereby agree that I, my heirs, distributes, guardians, legal representatives, and assigns will: (a) keep confidential the location, and details of the disaster and/or cruelty 1
Volunteer Agreement and Release of Liability investigation; (b) not make a claim against, sue, attach the property of, or prosecute the ASPCA for injury or damage resulting from the ASPCA or its affiliates, as a result of my voluntary assistance in a disaster and/or cruelty investigation situation; and (c) release, indemnify, defend, and hold harmless the ASPCA from all actions, claims, or demands I, my heirs, distributes, guardians, legal representatives, or assigns may have for injury or damage resulting from my assistance in a disaster and/or cruelty investigation situation. I HEREBY WARRANT THAT I (A) HAVE THE RIGHT TO ENTER INTO THIS AGREEMENT, (B) AM OVER EIGHTEEN (18) YEARS OF AGE, (C) HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENT, (D) AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN ME AND THE ASPCA, AND (E) SIGN THIS OF MY OWN FREE WILL. VOLUNTEER ASPCA PRINTED NAME PRINTED NAME SIGNATURE SIGNATURE 2