“Animals are a catalyst for positive change”

VOLUNTEER APPLICATION
Please completely provide all of the information requested below. Do not state, “see resume” or similar language.

Date      

1. PERSONAL

Name - Last       First       M. I.       Are you 21 years or older? (Programs only) Yes No
Street Address     
Phone: Home (       )       Cell (      )     

City       State       Zip Code      

Email      

Emergency Contact :       Phone: (      )      Other Names Used      

2. VOLUNTEER POSITION APPLIED FOR

Position       Date Available     

Hours Available       How many days a week?      

3. EMPLOYMENT (List most recent experience first. If additional space is needed, please attach a separate page.
Job Title & Duties Performed
Name, Address & Telephone # of Previous Employer Dates Date

      Starting Position From To

                       
     
Ending Position
Immediate Supervisor:                  

May we contact? Yes No Duties:

Reason for leaving:     

Name, Address & Telephone # of Previous Employer Starting Position From To

           
                 

Ending Position
     
           
Immediate Supervisor:      

May we contact? Yes No Duties:

     
Reason for leaving:      

Burgess Family Farm

4440 Solano Road, Fairfield CA 94533
(707) 290-6753
 “Animals are a catalyst for positive change”

VOLUNTEER APPLICATION
Please completely provide all of the information requested below. Do not state, “see resume” or similar language.

4. EDUCATION

School - Circle highest year completed: 6 7 8 9 10 11 12 <12 Completed G.E.D.? □ Yes □ No

Name of High School, University, College, or Business School & Major No. Years No. Units Diploma/ Degree Date
Location Subject Completed Completed or Certificate Graduated

                                   

                                   

Employment Related Education or Training

Course Title Name of School or Organization No. Hours No. Hours

                       

                       

5. REFERENCES
List 3 persons who can give information about your work experience, skills, character, and abilities (at least 2 references must be past employers or
professionals):

Name Address Telephone Nature of Acquaintance

            (H)            

(W)      

            (H)            

(W)      

            (H)            

(W)      

6. PROFESSIONAL AND TECHNICAL QUALIFICATIONS

A. List work-related licenses or certificates of competence currently held:      

B. Have you ever had a professional or work-related license revoked or suspended? Yes No
If the answer to the above question is yes, please explain (attach extra paper if necessary):
     

C. Names of professional associations of which you are a member:

     

Burgess Family Farm

4440 Solano Road, Fairfield CA 94533
(707) 290-6753
 “Animals are a catalyst for positive change”

VOLUNTEER APPLICATION
Please completely provide all of the information requested below. Do not state, “see resume” or similar language.

7. OTHER INFORMATION
Can you perform the essential functions of this position with or without reasonable accommodation? Yes No

Except for minor traffic offenses, have you ever been convicted of a criminal offense or entered a plea of “Guilty,” “No Contest” or had a withheld judgment to a criminal
offense? Yes No

If the answer to the above question is yes, please list all and explain (attach extra paper if necessary). A criminal conviction does not necessarily disqualify you for
employment. You must be prepared, if requested, to provide documentation confirming the information you provide about your conviction. :
     

Are you legally eligible for employment in the U.S.? Yes No If hired, can you show proof of authorization to work in the
U.S.? Yes No

Are any of your relatives currently employed by the Burgess Family Farm? Yes No If yes, in what program/store?       Position?      

Do you possess a valid California driver’s license? Yes No If No, can you get one within 30 days? Yes No

8. AREA OF INTEREST
Please indicate the areas that interest you:
Tutoring / Mentoring Fundraising Bulk Mailings
Educational Liaison Grant Writing Office/Reception
Animal Handler Web Design Working with Computers
Ranch Hand Community Outreach Special Projects

Burgess Family Farm

4440 Solano Road, Fairfield CA 94533
(707) 290-6753
 “Animals are a catalyst for positive change”

VOLUNTEER APPLICATION
Please completely provide all of the information requested below. Do not state, “see resume” or similar language.

9. WAIVER AND RELEASE

I hereby authorize Burgess Family Farm, hereafter referred to as “Company,” to publish photographs taken of me, and my name and likeness, for
use in the Burgess Family Farm's print, online and video-based marketing materials, as well as other Company publications.

I hereby release and hold harmless Burgess Family Farm from any reasonable expectation of privacy or confidentiality associated with any
images.

I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking
or publication of these photographs or participation in company marketing materials or other Company publications. I acknowledge and agree
that publication of said photos confers no rights of ownership or royalties whatsoever.

I hereby release Burgess Family Farm, its contractors, its employees, and any third parties involved in the creation or publication of marketing
materials, from liability for any claims by me or any third party in connection with my participation.

Authorization

Signature of Volunteer___________________________________________________ Date_____________________________

Signature of Parent (if under 18 years)_________________________________

Date_____________________________
10. CERTIFICATION

My signature below certifies that all information in this application is correct and complete to the best of my knowledge and belief, and I
understand that intentionally giving false or incomplete information may result in refusal of volunteer services or termination of
volunteer services if discovered after the start date. I also authorize the employer or persons of Burgess Family Farm to provide
information regarding my employment, education, character and qualifications. I understand that information obtained from the
above persons or others will be used for the purpose of making volunteer service related decisions and that the results will be kept
strictly confidential.

I understand that pre-service drug testing may be required for this position. If a criminal background check or medical examination is
required for the position for which I am applying, any offer is contingent upon satisfactory completion of such background check and/or
testing.

I also understand and agree that if selected, my volunteer service is for no definite period and either the Agency or I may terminate our
relationship at will at any time without notice or reason and that this application does not constitute a contract.

Signature of Volunteer___________________________________________________ Date_____________________________

Signature of Parent (if under 18 years)_________________________________ Date_____________________________

Burgess Family Farm
4440 Solano Road, Fairfield CA 94533
(707) 290-6753
 “Animals are a catalyst for positive change”

VOLUNTEER APPLICATION
Please completely provide all of the information requested below. Do not state, “see resume” or similar language.

Oh a separate piece of paper briefly write why you are interested in volunteering at the Burgess Family Farm, what you
would like to learn or accomplish from this experience, and what experience you have working with animals.

Burgess Family Farm

4440 Solano Road, Fairfield CA 94533
(707) 290-6753