JUNIOR VOLUNTEERS

PERMISSION & RELEASE FORMS

The New Rochelle Humane Society

70 Portman Road, New Rochelle, NY 10801

PH:914-632-2925

FAX:914-632-0445

Permission & Release Form for Junior Volunteer(s)

This form is to be filled out by parent or legal guardian along with youth volunteer.

Please read and complete this form, sign it and return it to us.

Please Print All Information!

Please circle one:                           Parent     Legal Guardian

Parent’s/Legal guardian’s name: ______________________________________________________________

I give permission for the following child/children to participate in the New Rochelle Humane Societies 
activities:

Child’s name: ____________________________________________________ Age ___________

Child’s name: ____________________________________________________ Age ___________

D.O.B.: month _____________________ day _________year________________

Address (street)________________________________________________________________

City: _______________________________________________ State:_________ Zip: _____________

Daytime phone #: ____________________________  Evening phone #: ___________________________

Emergency phone #: _________________________E-mail address:______________________________

School attending: _________________________________________________________________

Describe experience with dogs and cats:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Do you presently own any cats or dogs?

___________________________________________________

Permission and Release of Liability

Please Initial

_______          My child/children will abide by the mission, rules, regulations, policies and programs of the 
New Rochelle Humane Society while I am a volunteer.

_______          I assume the risks of my child/children being bitten, scratched, injured or frightened by cats, 
kittens, dogs and puppies in connection with my volunteer work for the New Rochelle Humane 
Society.

_______          The New Rochelle Humane Society is not liable for any injuries, damages, liabilities, losses, 
judgments, costs or expenses whatsoever, which my child/children might suffer or sustain in 
connection with the performance of their volunteer activities for the Humane Society.

_______          I hereby release and indemnify, defend and hold harmless the New Rochelle Humane Society, 
its directors, officers, employees, agents, and volunteers and their heirs, successors, assigns 
personal representatives from and against liability.

_______          I have accurately and truthfully completed this volunteer application.

Parent/Guardian            Youth Volunteer Applicant

_______________________________________________________________________

Sign name                                                                                               Sign name

Print name______________________________Print name: _______________________

Date______________________________           Date ____________________________

FOR OFFICE USE ONLY

Shelter Manager/Assistant Manager                                        Youth Volunteer Coordinator

Sign name         ____________________________               Sign name          ___________________________

Date  __________________________                                    Date________________________________

Print name ________________________________   Print name ____________________________

Date______________________________                    Date________________________