Any person in need of Community Hours who follows the Program Guidelines may be allotted Community Hours

Date      ___________________________________School Credit______Court  Appointed_____

NAME: ___________________________________PHONE NUMBER:_______________________________

ADDRESS: _______________________________________________________________________________ 

CITY / STATE / ZIP________________________________________________________________________

EMAIL: __________________________________________________________________________________

SCHOOL / PERSON NAME:  ________________________________________________________________

CREDIT WILL BE GIVEN FOR SERVICE, FOOD OR SUPPLIES LISTED BELOW:

 FOSTER VOLUNTEER  ( 4 HOURS PER DAY) _____SITE VOLUNTEER _____

BEHIND THE SCENES VOLUNTEER______COLLECTION OF SUPPLIES_______

 ITEMS/HOURS         COLUMN A                                               ITEMS/HOURS                    COLUMN B                                         

            _____/_____Science Diet Puppy Food @3cans =1.5hrs.                               _____ /_____Small Bite Puppy Food @1Bag =5hrs.

           _____/_____Towels @ 5 towels = 2.5hrs.                                                              _____/_____Clothes Detergent @ 1 gallon = 4hrs.

           _____/_____Bleach @ 1 gallon = 2hrs.                                                                    _____/_____Paper Towels @ 12 pack roll = 6hrs.

           _____/_____Pet Toys @ 2 toys = 2hrs.                                                                   _____/_____ Pet Treats @ 1 bag = 2hrs

           _____/_____Leashes/Harnesses/Collars                                                                  _____/______Dawn Dish Detergent Original

                                         @ each item = 0.5hrs                                                                                                                               @ each item = 1.5hrs

          _____/_____SUBTOTAL   A                                                                                        *____/_____SUBTOTAL   B   *

____/_____ Gift Card(s) COLLECTED can be from pet markets, office supplies, super market, gas cards, etc.

                        @ $10.00 gift card = 6hrs.

_____/_____Monetary Donations COLLECTED @ $10.00 gift card = 6hrs

                        To be used for Vet Exams, Medicine, Spay/Neuter, Vaccines and so much more.

*____/_____SUBTOTAL   B   *

_____/_____ Miscellaneous Hrs to include but not limited to: phone calls, printing flyers, thank you notes, etc.

                        _____________________________________________________________________________

                        _____________________________________________________________________________

_____/_____TOTAL HOURS OF COMMUNITY SERVICE RENDERED.

 COLLECTION VOLUNTEER COORDINATOR: Sheryl R. Tautiva (561) 667-0753

SIGNATURE:_________________________________________DATE_______________________________

PARENT /GUARDIAN /PARTICIPANT:_______________________________________________________

SIGNATURE: ________________________________________DATE_____________HOURS____________

We thank you on behalf of all the homeless animals that will receive food, shelter, medicine and love because of your hard work and devotion. We honor you!!!