Confidential
VOLUNTEER APPLICATION FORM
Section 1
Your Full Name……………………….…..………………………Mr/Mrs/Miss
Address…………………………………………………………………………
……...……………………………………………………………………………
Post Code….…………………………………Date of Birth…………………..
Home Tel:…………………………………. Work Tel …………….….…….
Mobile Tel……………………………………………………………………...
email address (if applicable)………………………………………….............
What is the best way to contact you? ........................................................
What is usually the best time to contact you?............................................
Are you currently in good health? ……………………………………Yes/No
Emergency Contact Name …………………………..Tel No………………
Where did you first hear about Keep Your Pet?…………………………….
Which Keep Your Pet service/s could you help to provide (please
tick as appropriate)
Dog Walking
please also complete sections 2 & 3
Visiting to feed an animal in its own home
please also complete sections 2 & 3
Taking an animal to the vet
please also complete sections 2 & 3
Fostering an animal
please also complete sections 2 & 4
When you have completed all the relevant sections, please return your
application to: Keep Your Pet, c/o Age UK York, 7a Acomb Court,
Front Street, Acomb, YORK YO24 3BJ
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Confidential
VOLUNTEER APPLICATION FORM
Section 2 (to be completed by all volunteers)
Please give the names and addresses, including titles and post codes, of two
referees (not related to you) who have known you for at least three years. One
referee should ideally be known to you in a professional capacity.
1. Mr / Mrs / Miss / Ms / Other (Please specify)
2. Mr / Mrs / Miss / Ms / Other (Please specify)
Name: ………………………………
Name: ……………………………………,
Address: ……………………………
Address: ………………………………….
……………………………………….
……………………………………………..
Post Code: …………………………
Post Code: ……………………………….
Tel. No………………………………
Tel. No……….………………………........
Relationship to you…………………
Relationship to you……….……………
How long have they known you?.....yrs How long have they known you?........yrs
Have you been convicted of a criminal offence?…………………..…………..YES/NO
(This volunteer post is exempt from the Rehabilitation of Offenders Act 1974 and you are required to reveal all convictions,
even those which are spent. A criminal record will not necessarily be a bar to obtaining a position.)
In the event that your application is successful, our policy requires a submission to the
Criminal Records Bureau.
Confidentiality Statement
RSPCA York & District Branch and Age UK’s York & Selby staff and volunteers must ensure
that any personal information disclosed to them in the course of their work is treated as
strictly confidential and should only be disclosed to those who need to know with the consent
of the person concerned. An exception to that general rule can be made if the person is at
risk or is putting others at risk. Any matter of concern must be reported to the managers of
Keep Your Pet (RSPCA York & District Branch/Age UK’s York & Selby) so that they can
decide on appropriate action.
Data Protection statement
Your information will be stored and used in accordance with the Data Protection Act 1998.
RSPCA York & District Branch and Age UK’s York and Selby will not pass your information
to any party for use in a commercial way. Your information will be stored centrally and Keep
Your Pet managers will have access to your information.
Please sign your name below to show that you accept the confidentiality statement, data
protection statement and that the details that you have given in this form are correct to the
best of your knowledge.
Signature……………………………………………………………...
Date………………………
RSPCA York & District Branch
Registered charity no. 232222
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Confidential
VOLUNTEER APPLICATION FORM
Section 3
Please
complete this section if you are volunteering
Walk a dog
Visit to feed an animal at its own home
Take an animal to the vet
to
Which kind/s of animal would you prefer to help ?.....................................
eg dogs, cats, rabbits etc)
Are there any animals that you would not want to work with? YES/NO
If YES which animal/s do you not want to work with?………………………
Which areas of York and the surrounding villages are you able to visit?
(Please tell us the area/s or the maximum distance you can travel from
your home. Please note that unfortunately we are not able to pay travel
expenses)
……………………………………………………………………………………
……………………………Do you have access to a vehicle ?.....YES/NO
If yes, do you have a full/clean driving licence?……………… YES/NO
Are you prepared to carry an animal in your vehicle?.................YES/NO
Would you be willing to visit the home of a pet owner who smokes?
YES/NO
Do you have any other personal preferences or restrictions on the
support you could give?..............................................................................
……………………………………………………………………………………
Which day/s of the week are you usually available?*………………………
……………………………………………………………………………………
What time/s of day would you usually be available?* ................................
* This is just for guidance. We will always consult you to confirm your availability for any
specific volunteering work. If you have no fixed pattern to your availability, please put
‘Varies.’
Signature……………………………………….........................Date………...
Confidential
VOLUNTEER APPLICATION FORM
Section 4
FOSTERING ASSESSMENT QUESTIONAIRE
Please complete in BLOCK CAPITALS and tick the appropriate boxes
Can you foster
either a:
Dog
Cat
Bird
Is your home
rented ?
Yes
No
Other (please specify)
If rented are you
the authorised
tenant?
Yes
No
Please note a letter from your landlord to confirm
that pets are allowed in the property must be supplied
Is your home a
House
Flat
Other (please specify)
Do you have a
Yes
private secure
garden
If Yes what is the current
minimum height of the
fence
No
Do you live near
a busy road?
No
Yes
For cats only
Do you have a cat flap?
If Yes are you happy to
close the flat and keep a
cat indoors?
.Please note: the height must be over 6
feet for some breeds of dog.
Height is:
Yes
No
Yes
No
For all animals
Where do you intend to house the
foster animal?
For how many hours a day will
the foster animal regularly be left
accompanied?
Have you had a pet before?
Please give details of the
veterinary surgeon you normally
use?
Others (please specify)
Indoors
hours a day
Yes
No
My usual vet is:
Outdoors
If Yes, what kind of animal/s and for
approximately how long?
How active are you?
Very
Reasonably
Not very
Please give the details of all the people sharing your home, including children.
.
Age
Name & relationship to you
1
2
3
4
5
6
Do you have visiting children?
Yes
No
If Yes, please give their ages:
Please give the details of ALL animals you currently have:
Species
Sex
Neutered?
Vaccinations in the last
M/F
Yes or No
twelve months
Do any other animals ever visit your
home?
Yes
Comments
No
Any other information you wish to supply?
Please tick next to each statement to confirm you understand and agree that:
Full liability for any veterinary fees incurred at any future date remain the
responsibility of the fosters pet’s owner
Although we will tell you everything we can about the animal, we do not always have
a complete history and therefore cannot guarantee behaviour etc.
RSPCA York and District Branch are here to offer advice on any aspect of caring for
the animal; you can call them on 01904 654949, during working hours, seven days a
week.
Signed.........................................................................................
Date....................
RSPCA York & District Branch
Registered charity no. 232222