Canine Therapy Volunteer Application

Thank you for your interest in volunteering at Covenant HealthCare! Please allow yourself approximately 15 minutes to accurately and thoroughly complete this volunteer application. If you have trouble completing this application, please contact Volunteer Services, 989.583.4189.

New User Details

User ID

User ID (verify)

Password

Password (verify)

Applicant Information

* First name

* Family/last name

Preferred First Name

* Date of Birth

* Home address

* City

* State

* Zip Code

* Primary phone

Mobile phone

Work phone

* E-mail address

Gender

Race/Ethnicity (Optional)

Are you a veteran? (optional)

Emergency Contact Information

* Contact name

* Primary phone

E-mail address

* Relationship

Dog Information

* Dog Name

* Dog Breed

* Date of Dog Birth

Gender

Neutered/Spayed

Dog Weight

My dog is currently certified with

Certification Date

References

Please provide name and phone number for two references. Do not list relatives.

* Name

E-mail

* Phone

Relationship

* Name

E-mail

Phone

Relationship

Employment History

Have you ever worked or volunteered at Covenant HealthCare?

If yes, in what capacity and when?

Please list information for your two most recent employers.

Employer Name

Employer Address

Dates of Employement

Job Title

Type of Work

Reason For Leaving

Employer Name

Employer Address

Dates of Employement

Job Title

Type of Work

Reason for Leaving

Volunteer Experience

Other volunteer services you have participated in. Please include type of duties performed.

Education

Highest Level of Education Completed

High School

City/State

College

Degree/Major

Other Professional Training:

Skills and Scheduling

* Please share with us why you would like to volunteer at Covenant HealthCare and what skills you would bring to our organization.

Are you completing this application for school or a community related service (i.e. Michigan Works)

If yes, please explain:

All volunteers will be required to work minimally 3-4 times per month.

Select the days you are available to volunteer

Select the time of day you would like to volunteer

What amount of time are you prepared to share with us?

If other commitments than above (less than 6 month commitment or specific hours), please specify:

Additional Information

Additional information or comments you would like to share with us prior to interview?

Have you ever been convicted of a crime, including a misdemeanor?

Are there any legal charges pending against you?

If yes (legal charges pending) please explain:

Are you volunteering to satisfy a court ordered probation?

If yes, please list probation officer's name and phone.

Authorization and Signature

* I understand the time and financial commitment involved with becoming a certified dog handler. I also understand I am required to fulfill all of the requirements outlined in the Canine Therapy Program at Covenant HealthCare. I fully accept all the terms and conditions stated here.

* I certify that the responses on this application are true to the best of my knowledge. I agree that this information may be verified and my references may be contacted by Covenant HealthCare Volunteer Services. I authorize Covenant HealthCare to perform all necessary background checks and understand my date of birth is necessary for these checks. If accepted for volunteer placement, I will comply with the values, policies and procedures of Covenant HealthCare in effect or revisions which may be issued in the future.  Misrepresentation of facts constitutes cause for separation from volunteer placement. I understand that the position that I am applying for is an unpaid volunteer position.

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E-Signature