Community Service Application

Please select your gender pronouns(Required)

Do you understand that your service hours will not include animal interaction?(Required)

Legal name as it appears on your ID/Driver's License(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Are you at least 18 years of age?(Required)

Birth Date(Required)

Availability Information

Total number of hours you need to complete at IndyHumane:(Required)

Please note: You must be in need of a minimum of 20 hours to be eligible for this program.

Will you need a confirmation letter upon completion of your hours?(Required)

Date you are able to start performing service:(Required)

Date by which hours need to be completed:(Required)

We are able to accommodate service hours during the following times: Monday through Friday in between the hours of 9-6pm at 2-6 hour intervals per day Saturday in between the hours of 9:30-6pm at 2-6 hour intervals per day Sunday in between the hours of 9:30-4pm at 2-6 hour intervals per day You must be able to start your hours by 12pm.

Please mark the days you are available to perform your service hours.(Required)

Sunday hours available: 9am - 4pm (must start shift by 12pm)

Monday hours available: 9am - 6pm (must start shift by 12pm)

Tuesday hours available: 9am-6pm (must start shift by 12pm)

Wednesday hours available: 9am - 6pm (must start shift by 12pm)

Thursday hours available: 9am - 6pm (must start shift by 12pm)

Friday hours available: 9am - 6pm (must start shift by 12pm)

Saturday hours available: 9:30am - 6pm (must start shift by 12pm)

The hours you mark will be used to determine your schedule until your hours are completed. You must be able to start your hours by 12 PM.

Please record any dates that fall within your availability which you are unable to perform service hours.

Order for Service Information

You are not eligible for this program if you have a felony, theft charge or conviction, or have been convicted of any sexual, violent, or animal cruelty related crimes. You will need to provide documents supporting your order for service. Your hours must be court ordered or needed for a class or community group in order to be eligible for this program.

Are you a registered sex offender?(Required)

Are your hours:(Required)

Your application will not be reviewed if there is no valid contact person listed. Do NOT list yourself.

Full name of person in charge of overseeing your service hours are completed/ to which you will report completion of hours (Case Worker, Probation Officer, etc): *(Required)

First Last

Email address for person in charge of overseeing your service hours are completed:(Required)

Phone number for person in charge of overseeing your service hours are completed:(Required)

What charge/conviction is the reason you are ordered to perform service hours? Use full words (no initials/abbreviations) to describe the exact charge. If you are in a Diversion Program or in Violation of Probation, you must list the original crime that was the reason for the arrest. *(Required)

Medical/Emergency Information

You should record any information you believe is important for IndyHumane to be aware of in case of an emergency.

Name of Emergency Contact(Required)

First Last

Relationship to You(Required)

Email Address for Emergency Contact

Phone Number for Emergency Contact(Required)

Alternate Phone Number for Emergency Contact

Do you have medical conditions/allergies of which IndyHumane should be aware?(Required)

Are you currently taking medications of which IndyHumane should be aware?(Required)

Volunteer Waiver/Release

Parental signature needed for minors. Typing your name below acts as your electronic signature.(Required)

First Last

Comments/Questions: