For Office Use Only
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Date: _______________

APPLICATION FOR VOLUNTEER SERVICES 
(PRINT OUT THIS FORM) 

Your interest in HABIT is greatly appreciated. Please complete this application and return it to: HABIT/UTCVM, Dept of Comparative Medicine, College of Veterinary Medicine, 2407 River Dr., Rm. A205, Knoxville, TN 37996-4543, Tel: (865)974-5633

(Mr.,Ms) Name:____________________________________________________________
(Please Print)     First                       Middle                         Last
Home Address ____________________________________________________________
                                Street
City , State Zip ____________________________________________________________

Home Telephone:  _________________  Work Telephone ________________

Email: ___________________________________________________________________

Social Security No. ____-____-____  Birth date (optional) _________

HABIT MEMBERSHIP DUES

HABIT is a non-profit organization. Annual membership dues are required and help cover mailing costs of materials sent to you and help us continue our services. Annual Membership Dues: $15 per household. Additional contribution $_____________.

HABIT MEMBERSHIP OPTIONS (Please check all that are appropriate.)

____Please enroll me as a member of HABIT. I wish my animal to be medically and behaviorally evaluated. My dues are enclosed and I have or will attend a HABIT Information Meeting.

____I do not wish to volunteer with an animal, however, I wish to become a member of HABIT by paying the annual dues and under- stand that I will receive HABIT's newsletter and information regarding HABIT events. (It is not necessary to complete the remainder of the application if this is your option.)

____I would like to volunteer with a HABIT Loaner Animal if an appropriate animal is available. I understand I must attend a HABIT Information Meeting. My membership dues are enclosed. (CONTINUED ON THE BACK)

____I do not wish to participate in animal visitation, but I would like to volunteer my pet as a HABIT Loaner Animal. I under- stand I must still attend HABIT's Information Meeting and have my animal medically and behaviorally evaluated. My membership dues are enclosed.

VOLUNTEER INFORMATION
Occupation: ______________________________________________________________________________
Employer: ________________________________________________________________________________
Experience or special skills, hobbies or interests that would be helpful in visits. _______________________________________________________________________________________ _______________________________________________________________________________________
Would you be interested or have the time to volunteer in the office?___________________________________
How did you hear about HABIT?_____________________________________________________________

PET INFORMATION
Please complete this portion only if you have an animal you wish to be evaluated (loaner animals included).

Pet Name ________________Breed/Type _________________ Size_______ Age of animal___________
Sex of animal _________
Neutered: Yes ______No _______

VOLUNTEER WORK PREFERENCE
The HABIT volunteer coordinator will attempt to meet your preference after current facility needs are reviewed. The majority of our facilities serve the elderly with fewer opportunities to visit other age groups.

If possible, I would like to visit: (more than one may be checked)

Elderly_____Adults_____Adolescents ______Children_____

Please indicate day(s) of the week you are available to volunteer:

Mon.___ Tues.___ Wed. ___ Thurs.___ Fri.___ Sat. ___ Sun.___
Times Available: Morning ___ Afternoon ___ Evening ___

Signature_______________________________________________________  Date____________________

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