SCVRC Volunteer Application Thank you for your interest in applying for SCVRC membership. Please answer all of the questions. Question Title * 1. By answering YES to this multi-point question I am certifying that I wish to volunteer with the South Carolina Veterinary Reserve Corps ("SCVRC") and I further certify my understanding and agreement regarding all of the following statements with regard to SCVRC membership: The information I provide on my SCVRC application is correct to the best of my knowledge. I understand that the nature of the volunteer activities that I may perform in my capacity as a volunteer for SCVRC may place me in emergency situations, and may further involve physical activity, contact with unidentified and/or unfamiliar animals and persons, or other potential risk of bodily injury or damage to property. Knowing this, I HEREBY ASSUME FULL AND COMPLETE RESPONSIBILITY FOR ANY PERSONAL INJURY AND/OR PROPERTY DAMAGE THAT I SUSTAIN OR CAUSE DURING MY PARTICIPATION AS A VOLUNTEER. I understand that while I am engaged in training and deployments as a volunteer that I am not an employee, agent, or contractor for the SCVRC. I understand that as a volunteer I will not receive any monetary compensation from the SCVRC. I understand that to become an SCVRC volunteer I must possess my own personal medical insurance, disability insurance, professional liability, general liability, and medical malpractice insurance where applicable. I understand that the SCVRC and its affiliates will not provide any medical or disability insurance, professional liability insurance, or workers compensation insurance benefits to its members while they are either training or volunteering as SCVRC volunteers. I understand that the SCVRC may provide general liability insurance during some training and volunteer activities. In the events that this insurance is provided, acts of gross negligence or willful misconduct will be excluded from this coverage. SCVRC makes no representations as to whether it will provide any such insurance coverages, and volunteers are advised to proceed on the assumption that no such coverage will be provided. I hereby release and hold harmless AND COVENANT NOT TO FILE SUIT AGAINST SCVRC, THE SOUTH CAROLINA ASSOCIATION OF VETERINARIANS (SCAV), OR ANY OF THEIR EMPLOYEES, VOLUNTEERS, MEMBERS OF THEIR BOARDS OF DIRECTORS, AND ANY AGENTS, REPRESENTATIVES AND ASSOCIATED AGENCIES (THE "RELEASED PARTIES") FROM ANY AND ALL LOSS, LIABILITY OR CLAIMS FOR ANY INJURY TO ME OR DAMAGE TO MY PROPERTY WHICH MAY RESULT FROM, OR IN THE COURSE OF, MY PARTICIPATION AS A VOLUNTEER. I HEREBY AGREE TO INDEMNIFY SCVRC AND/OR ANY OF THE RELEASED PARTIES (AS DEFINED ABOVE) FOR ANY CLAIMS OR DISPUTES OF ANY KIND ARISING OUT OF MY NEGLIGENCE OR WILLFUL MISCONDUCT DURING MY SERVICE AS A SCVRC VOLUNTEER. I authorize a background check to be performed by the SC Law Enforcement Division (SLED), and other verification of application information, and I understand that the SCVRC will use this information only as part of its verification of my volunteer application. I hold the SCVRC and supporting agencies harmless of any liability, criminal or civil, which may arise as a result of the release of this information about me. I also hold harmless any individual or organization that provides information about me to the SCVRC. I consent to the unrestricted use by SCVRC and/or persons authorized by SCVRC of any photographs, recordings, interviews, videotaped motion pictures or other similar visual recordings of me while volunteering with SCVRC. I understand that I may decline when contacted for SCVRC volunteer deployment opportunities. I understand that I may withdraw my application or discontinue my membership in the SCVRC at any time with written notification to the SCVRC Unit Leader. I agree to abide by the SCVRC Volunteer Code of Conduct. YES No The SCVRC Volunteer Code of Conduct is found on Page 5 of this application as well as in the SCVRC Volunteer Handbook on the SCAV.org website under Emergency Preparedness. Applicant Information Question Title * 2. Title (Mr., Mrs., Ms., Dr.) Question Title * 3. Last name Question Title * 4. First name Question Title * 5. Middle initial Question Title * 6. Home address Question Title * 7. City Question Title * 8. State (Abbreviation) State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Question Title * 9. Zip Question Title * 10. What county do you live in? Question Title * 11. How did you get referred to the SCVRC application (choose from list)? At a SCAV meeting or local veterinary association meeting My employer or co-worker at a veterinary hospital From an SCVRC Unit Leader From my SC County Emergency Management office Other (please specify) Question Title * 12. Driver’s license/State ID# Question Title * 13. Driver's license State State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Question Title * 14. Driver's License Expiration Date Date / Time Date Question Title * 15. Date of birth (mo/dd/yyyy) Date Date Question Title * 16. Gender Male Female Question Title * 17. Email address Question Title * 18. Office telephone number Question Title * 19. Mobile telephone number Question Title * 20. Do you use the texting feature on your mobile phone? Yes No Question Title * 21. Additional telephone number(s) Question Title * 22. Employment status Full-Time Part-Time Retired Not working outside the home Question Title * 23. Employer (If applicable) Question Title * 24. County of employment Question Title * 25. Job title (if applicable) Question Title * 26. Are you self-employed? Yes No Not applicable Supervisor name (if applicable) Question Title * 27. Best way to contact you quickly - first choice Phone Email Text Other (please specify) Question Title * 28. Best way to contact you quickly - second choice Phone Email Text Question Title * 29. May we contact you 24 hours a day/7 days a week? Yes No Morning only Afternoon only Evening only Acceptable times to contact me: Emergency Contact Information Question Title * 30. Name of Emergency Contact Question Title * 31. Relationship to you? Question Title * 32. Phone number(s) 12% of survey complete. Next