All applicants should complete section 1
Section 1
Your FullName………………………………………….…..………………………Mr./Mrs./Miss/Ms.
Address………………………………………………..…………………..……………………………
Post Code….…………………………………………………………Date of Birth……….…………..
HomeTel:……………………...... ……………. Mobile…..……………..………….……...…….
Email address ……………………………………………………………………………….…......
Emergency Contact Name ……………………..………………..Tel No……………………..………
Are you currently in good health? Yes/No
Do you have and medical conditions we need to be aware of? Yes/No
Please give details………………………………………..……………………………………………
Do you have a full driving licence? YES / NO Access to a car? YES / NO
Do you have business use on your car insurance? YES / NO
Which Keep Your Pet service/s could you help to provide (please tick as appropriate)
Dog Walkingplease also complete sections 2 & 3
Feed an animal at 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
Admin only please also complete section 2
Please tick this box if you do not want your details passing onto the fundraising committee and do not wish to be involved with fundraising for Keep Your Pet.
Where did you first hear about Keep Your Pet?…………………………………………….…….
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: ……………………………
Email ………………………………… Email ………………………………….
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’sYork & 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 YorkSelby) 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 & DistrictBranch 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 KeepYour 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.
Section 3
Please complete this section if you are volunteering to
Walk a dog
Visit to feed an animal at its own home
Take an animal to the vet
Which kind/s of animal would you prefer to help ?......
(e.g. dogs, cats, rabbits etc)
Are there any animals that you would notwant 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? YES/NO
Please give details ……….……………………………………………………………………………………
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.’
Section 4FOSTERING ASSESSMENT QUESTIONAIRE
Please complete in BLOCK CAPITALS and tick the appropriate boxes
Can you foster either a: / Dog / Cat / Bird / Others (please specify)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 private secure garden / Yes / No
If Yes what is the current minimum height of the fence / Height is: / Please note: the height must be over 6 feet for some breeds of dog.
Do you live near a busy road? / Yes / No
For cats only
Do you have a cat flap? / Yes / No
If yes are you happy to close the flap and keep a cat indoors? / Yes / No
For all animals
Where do you intend to house the foster animal? / Indoors / Outdoors
For how many hours a day will the foster animal regularly be left unaccompanied? / hours a day
Have you had a pet before? / Yes / No / If Yes, what kind of animal/s and for approximately how long?
Please give details of the veterinary surgeon you normallyuse? / My usual vet is:
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
M/F / Neutered?
Yes or No / Vaccinations in the last 12 months / Comments
Do any other animals ever visit your home? / Yes / 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 pet 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.
Please return the completed application form to
Age UK York,
C/O York CVS
Priory Street,
York,
YO1 6ET
Signed...... Date......
RSPCA York & District Branch Registered charity no. 232222