Virginia State Animal Response Team

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Volunteer Application Form

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

Name*
FirstLast
Address*
Street AddressCityStateZip Code
Date of Birth*
Daytime Phone*
Evening Phone
Cell Phone
Email*
Skills / Experiences (mark all that apply)
- Veterinary Medicine
- Dog Trainer
- Communications / PR
- Livestock Handling
- Animal Groomer
- Computers/ Web Design
- Small Animal Handling
- Certified in Human First Aid
- Certified in CPR
- Administration / Management
- Exotics and Wildlife Handling
- Certified in Pet First Aid
- Fundraising
- Equine Handling
- Dog Club Member
- Photography
- Animal Sheltering
- Boarding Kennel Experience
- CDL License
- Wildlife Rehabilitation
- Customer Service
- Heavy Equipment Operator (i.e. forklift)
- Stable Management
- Amateur Radio Operator
- Driver’s License
Other (please specify)
Willing To Do (mark all that apply)
- Animal Care
- Animal Rescue
- Manage Phones
- Animal Health Care
- Office Work
- Damage Assessment
- Data Entry
- Driving
- Large Animal Transport
- Shelter Clean-up
*Training Experience (mark all that apply)
- VMD/DVM
- LVT
- HAZMAT Awareness
- Permitted Rehabilitator
- IS 100, current version (Intro to ICS)**
- IS 200a (ICS for Single Resources) **
- ICS 300 (Intermediate ICS)
- ICS 400 (Advanced ICS)
- IS 700 (NIMS Intro) **
- IS 800b (NRF Intro)
- IS 10 (Animals in Disasters)
- IS 11 (Animals in Disasters)
- IS 111 (Livestock in Disasters)
*See CART Roles and Responsibilities for required training or experience.
**Minimum requirement for deployment.
Vaccination / Medical History
Please mark all that apply and include date of vaccine if possible.
Rabies Pre-exposure
- Yes
- No
Date of Rabies Pre-exposure Vaccine
Rabies Titer
- Yes
- No
Date of Rabies Titer Vaccine
Titer Result
Tetanus
- Yes
- No
Date of Tetanus Vaccine
Hepatitis A
- Yes
- No
Date of Hepatitis A Vaccine
Hepatitis B
- Yes
- No
Date of Hepatitis B Vaccine
Seasonal Influenza Vaccine
- Yes
- No
Date of Seasonal Influenza Vaccine
Respirator Fit Tested
- Yes
- No
Date of Respirator Fit Tested
Do you have any physical restrictions/disabilities/chronic medical issues?
- Yes
- No
If yes, please describe below
Is there any additional health information you think would be important to disclose in case of a medical emergency while deployed?
- Yes
- No
If yes, please describe below
Do you have medical insurance?
- Yes
- No
Emergency Contacts
Please list below information about contacts in the event you are injured while deployed.
Primary Contact Name
FirstLast
Relationship to member
Address
Street AddressCityStateZip Code
Phone
Secondary Contact Name
FirstLast
Relationship to member
Address
Street AddressCityStateZip Code
Phone
Do you have your own transportation?
- Yes
- No
Do you have any equipment / products/resources that you could offer the team? If so, please describe below.
Additional Information
Please answer the following. For any affirmative response, please attach 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 us in making a membership decision.
Have you ever been convicted of animal cruelty or neglect?
- Yes
- No
Have you ever knowingly obtained an animal illegally?
- Yes
- No
Have you ever been arrested for, charged with, or convicted of a felony or non-traffic misdemeanor?
- Yes
- No
Please place a check next to each of the following statements to indicate that you have read and understand each one. *
- I understand that I may be subject to a background check as a part of the application process.
- I understand that my application may be declined for any reason without explanation.
- I understand that the supervising authority may dismiss me from the team for any reason 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 registration is subject to verification and I consent to credential and criminal history background checks. I understand that information contained here 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 the application does not guarantee that I have been approved as a Volunteer.

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.
Your Name
Date

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