Volunteering…

If you have an interest in helping others, especially animals, and contribute to your community in their timeĀ  of need, CART has an opportunity for you. All you need to do is submit the application below, complete a background check, and you’re on your way. We look forward to your application.

September 2009

Purpose: The purpose of this form is to gather contact, training, experience, and basic medical information from each volunteer. This information helps CART leadership to determine the skills and resources the team will be able to offer and helps identify any issues that leadership may need to take into consideration for each volunteer. Please note that it is the volunteer's responsibility to alert CART leadership with regard to any changes associated with this information, especially any changes that would effect their performance or abilities if deployed.

Name:*
Address:*
Date of Birth:*
Daytime Phone:*
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Evening Phone:*
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Mobile Phone:*
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E-mail Address:*

Skills / Experience (mark all that apply)

Other, (please specify):

Willing To Do (mark all that apply)

* Training Experience (mark all that apply)

* See CART Roles and Responsibilities for required training or experience.

** Minimum requirement for deployment.

Vaccination / Medical History (mark all that apply)

Rabies Pre-Exposure Date:
Tetanus Date:
Hepatitus A Date:
Hepatitus B Date:
Respirator Fit Date:
Seasonal Influenza Date:
Rabies Titer Date:
Rabies Titer Result:
Do you have any physical restrictions/disabilities/chronic medical issues?
If yes, please describe the restrictions/disabilities/chronic medical issues below:
Is there any additional health information you think would be important to disclose in case of a medical emergency while deployed?
If yes, please provide the additional health information below:
Do you have medical insurance?

Please provide the primary and secondary contacts to be notified in the event you are injured while deployed:

Primary POC Name:*
Primary POC Relationship to Member:*
Primary POC Address:*
Primary POC Daytime Phone:*
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Primary POC Evening Phone:*
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Primary POC Mobile Phone:*
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Secondary POC Name:
Secondary POC Relationship to Member:
Secondary POC Address:
Secondary POC Daytime Phone:
-
Secondary POC Evening Phone:
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Secondary POC Mobile Phone:
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Do you have your own transportation?
Do you have any equipment/products/resources that you could offer the team? If so, please describe below:

Please answer the following. For any affirmative response, please provide an explanation of the occurrence(s), making sure to include dates, agencies involved, case numbers, disposition, and any additional information that you feel would assist CART leadership with making a membership decision.

Applicants Last 4 SSN:
Have you ever been convicted of animal cruelty or neglect?
If yes, please provide an explanation of the conviction below:
Have you ever been arrested for, charged with, or convicted of a felony or non-traffic misdemeanor?
If yes, please provide an explanation of the charge(s) below:
Have you ever knowingly obtained an animal illegally?
If yes, please describe the event below:

Please input your full name, date of birth (mm/dd/yyyy), and last four of your Social Security Number in the space beside each question indicating that you have read and understand each one.

I understand that I may be subject to a background check as part of this application process:*
I understand that my application may be declined for any reason and without explanation.*
I understand that the supervising authority may dismiss me from the team for any reason and without explanation.*

I hereby certify that all entries on this registration form are true and complete. I agree and understand that any falsification of information herein, regardless of the time of discovery, may cause forfeiture on my part of my volunteer position in the service of the Commonwealth of Virginia. I understand that all information on this application is subject to verification and I consent to credential and criminal history background checks. I understand that information contained herein may be disseminated to other agencies, nongovernmental organizations or systems on a need-to-know basis for good cause shown as determined by the program coordinator or designee. I also understand that completion of this application does not guarantee that I have been approved as a volunteer/member of CART.

I understand that the Virginia State Animal response Team Board of Directors (VASART) and/or team coordinator or designee of any Community Animal Response Team (CART) will only use my personal information as it directly relates to my role as a volunteer with VASART or CART.

Applicants Name:*
Applicants Last 4 SSN: *
Application Date:*
Captcha Verification: