Compassion In Action (CIA) program Application
Please note: In order for your application to be processed, all fields must be completed along
with your full payment (check, cash, or money order) of $75.00 per session, which should be mailed to:
Humane Society Silicon Valley
Attention: Education Department
901 Ames Avenue
Milpitas, CA 95035
* Please complete one application form per student *
Please choose desired CIA session(s). If applicable, mark your 1st, 2nd, and 3rd choice. We will do our best
to accommodate your top choice. If you are applying to attend 2 sessions, please mark your top 2 choices
with a “1." Please note: If choosing to attend 2 sessions, CIA content and activities similar.
Make sure you will be able to attend all or most of the dates in that session.
Choice (1st, 2nd, 3rd) Session Number Session Dates
4 Tuesdays: Jan 19, 26, Feb 2, Feb 9 (3:30 – 5:30 pm)
Saturday: Feb 13 (1:30 – 4:30 pm)
5 Thursdays: Feb 18, 25, Mar 4, 11 (3:30 – 5:30 pm)
Saturday: March 13 (1:30 – 4:30 pm)
6 Wednesdays: Mar 17, 24, 31, Apr 7 (3:30 – 5:30 pm)
Saturday: April 10 (1:30 – 4:30 pm)
7 Wednesdays: April 14, 21, 28, May 5 (3:30 – 5:30 pm)
Saturday: May 8 (1:30 – 4:30 pm)
Student’s Name: Age: Grade:
Address: City: Zip Code:
Primary phone: Alternate phone:
Parent email address: Student email address:
Person to contact in an emergency: Phone:
CIA Application/Release - 1-
1) Do you have any allergies or special needs that we should know about?___________
2) What school do you attend? __________________How many service hours do you need? ____
3) Are these community service hours court ordered?___________________________
(Please note: we will not be taking court-ordered community service at this time.)
4) How did you hear about CIA? Please check all that apply.
______ Website ______HSSV staff
______ Friend, or Family _______Other, please explain _______________
5) Why do you want to be a part of the Compassion In Action program?
CIA ACCEPTANCE AND NOTIFICATION
• Applications are received on a first-come, first-served basis.
• Once your application and payment are received, education department staff will notify you within 7 days
by either email or phone of your acceptance.
• If you do not receive a confirmation within 7 days, please call us at
408. 262.2133 ext. 137 or email email@example.com
• If all CIA session(s) you requested are full at the time your application is received, you will be notified
and your check will be returned to you by mail.
Please feel free to contact us with any questions you have about “Amazing Animals” summer camp 2009. You
can call Jamie Haupt at 408. 262.2133 ext. 137 or her email firstname.lastname@example.org.
CIA Application/Release - 2-
Youth Program Release
Release of Liability - mandatory
In consideration of the Humane Society Silicon Valley accepting my child as an education student, I, the undersigned
parent or guardian of _____________________________, hereby agree to indemnify, defend and hold the Humane Society
Silicon Valley, its employees, volunteers and directors harmless for any and all damages, loss, or injuries my child may sustain
during his/her service activities. This Program Release form is executed without any reliance upon any representation by any
person and the undersigned has carefully read and understands the contents of this release form and executes the same as his or
her own free act.
I acknowledge and understand that education students are not covered by the HSSV's Workers Compensation or any
other insurance policy for any damages or injuries my child may sustain during his/her service activities.
In the event that any of the terms, conditions, and/or covenants contain in this release form are held to be invalid, such
invalidity shall not affect any of the other terms, conditions and/or covenants contained herein which shall remain in full force
Safety Contract - mandatory
The safety of youth participating in education programs at Humane Society Silicon Valley (HSSV) is a priority for us. Please
read and understand the following measures that may be taken at our discretion, if necessary, to ensure your child is safe and not
left at our facility unattended.
I understand that I must pick my child up no later than 10 minutes after the close of the program, unless otherwise discussed
with HSSV staff prior to the program. If I have not discussed this with HSSV staff and I do not pick my child up on time, I have
two choices. (Please make an “x” on the appropriate box & sign below).
I give HSSV the right to release my child from the program after it ends, even if I am later than 10 minutes. I understand
that my child will NOT be supervised during this time and HSSV will NOT charge me a late pick-up fee.
Yes, I would like my child to be supervised by HSSV staff if I am later than 10 minutes. I understand that HSSV will
charge a minimum of $1.00 per minute, per child, past time of pick up.
Parent/Guardian printed name Date
Photo Release (optional)
I, the undersigned parent or guardian of __________________________, hereby agree that the photographs and/or video images
taken of my child and his/her pet (or shelter animal) may be used in perpetuity by the Humane Society Silicon Valley for the
purposes of publicity, education, fundraising, or otherwise promoting the mission and activities of the Society. I understand that
I will receive no name recognition or monetary compensation for the use of said photograph (s) and/or video footage, to be used
either in print or on the HSSV website and that this agreement will remain binding and have legal effect regardless of whether my
association with the Humane Society Silicon Valley continues.
Parent/Guardian signature Date
CIA Application/Release - 3-