Volunteer Application

Kids & Horses

Therapeutic Riding Center

A Non-Profit Organization

Volunteer Application

General Information: The following terms and provisions and the information that I provide below, the Parental Release and Indemnity (if applicable), the Practitioner Statement (if applicable), and any other
documents that I may execute in connection herewith comprise my application (“Application”) to
participate as a volunteer in the instructional and/or therapeutic programs (individually or
collectively, (“Program”) provided by Kids & Horses, Inc. (“K&H”), my participation as a volunteer
in the Program, and my presence at the premises of K&H or any other locations at which the
Programs are conducted (collectively, "Participation" & "Participate"). I represent and warrant that the information that I provide below is true, complete and accurate, that I shall notify K&H in writing of any material changes to the information (for example, changes to my physical condition or health) and that K&H may rely on the accuracy thereof; all of which shall be a binding agreement between K&H and myself as of the Effective Date set forth below (“Agreement”).
For good and valuable consideration, including, without limitation, my being permitted to Participate in the Program, to enter the premises of K&H, and to utilize its facilities and equipment, the receipt and sufficiency of which is hereby acknowledged, I hereby agree as follows:

Name: *

Date: *

Address: *

City: *

State: *

Zip: *

Email: *

Date of Birth: *

Phone: (H) *

(W)

Employer/School: *

Address: *

Parent/Legal Guardian Name:

Address:

Goals (What would you like to accomplish or experience as a volunteer?): * *

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Last Tetanus Shot: *

Tuberculosis Test: *

Date: * 🛈

(Consult your physician or local health department if you are not up to date on these shots/tests)

Health History:

Please describe your current health status, particularly the physical/emotional demands of working in an Equine-assisted program. Address fitness, cardiac, respiratory, bone or joint functions, recent hospitalizations/surgeries, or lifestyle changes.

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Allergies: *

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Medications: *

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Check what areas you are interested in:

Program: *

Horse Handling

Sidewalking with a student

Stable Management

Facility Repairs

I understand that the information above is accurate to the best of my knowledge. I know of no reason why I should not participate in the events of this center's program.

Signature: *

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Date: *

Photo Release:

Photo Release Agreement *

I consent to authorize the use and reproduction by K&H (or its licensees or other third parties) of any and all photographs and any other audiovisual materials taken of me for promotional materials, educational activities, exhibitions, website, social media channels and/or for any other use for the benefit of the program.

I do NOT consent nor do I authorize the use and reproductions by K&H(or its licensees or other third parties) of any and all photographs and any other audiovisual materials in which the Volunteer appears recognizably, whether for promotional printed material, educational activities, exhibitions, website, Facebook or for any other use..I acknowledge that K&H is not responsible for the use of photographs and any other audiovisual material taken by other Volunteers, parents/legal guardians and/or their guests.

Consent to and authorize the use and production by Kids & Horses Therapeutic Riding Center of any and all photographs and any other audio/visual taken of me for promotional material, educational activities, exhibitions, or for any other use for the benefit of the center.

Signature of Volunteer: *

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Date: *

Background Information:

Have you ever been convicted of a crime? *

Yes

Please Explain:

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I, (Name) *

authorize Kids & Horses Foundation to receive information about me from any law enforcement agency, of this state or any other state or federal government, to the extent permitted by state and federal law, pertaining to any convictions I may have had for violations of state or federal criminal law, including, but not limited to convictions for crimes committed upon children or animals.

I understand that such access is for the purpose of considering my application as an employee/volunteer, and that I expressly DO NOT authorize the PATH center, directors, officers, employees, or other volunteers to disseminate this information in any way to any other group, agency, organization, or corporation.

Signature: *

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Date: *

CURRENT DRIVER'S LICENSE: *

Yes

License Number *

State: *

Confidentiality Agreement:

Policy of Confidentiality:

I agree to respect and observe privacy and confidentiality of all other Volunteers, volunteers and donors of K&H and not disclose or discuss any sensitive information about any person or their family such as, for example, any medical or health-related information about them. Among other things, this includes any photos, videos, images, blogs, vlogs or other statements on any social media channels, such as Facebook, Instagram, Tik-Tok, and YouTube, etc.

Signature: *

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Date: *

Signature (Parent/Legal Guardian): *

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Date: *

Volunteer Termination Policy:

Volunteering at Kids & Horses, Inc. is a privilege. We do appreciate all the skill, energy, and commitment volunteers bring to our programs. Sometimes it may be necessary to remove a volunteer from a specific class or the programs of Kids & Horses, Inc.

Please note that for the safety, security, and continuation of excellency in programming, an inattentive volunteer, or one who cannot perform the functions or duties of a volunteer, will be removed from classes and may be placed in other aspects of the program, or not be invited to return to Kids & Horses, Inc.

Absolutely no intoxicated or chemically impaired volunteer will be allowed to work/volunteer at Kids & Horses, Inc. If there may be a question, Kids & Horses, Inc.'s staff will err on the side of caution and not let the individual volunteer.

Volunteer/Staff's Initials: *

Authorization for Medical Treatment Form

Participant

Staff

Volunteer

Name: *

DOB: *

Phone: *

Address: *

Physician's Name: *

Preferred Medical Facility: *

Allergies to Medications: *

Current Medications: *

In the event of an emergency, contact:

Name: *

Relation: *

Phone: *

Name:

Relation:

Phone:

Name:

Relation:

Phone:

In the event emergency medical/aid treatment is required due to illness or injury during the process of receiving services, or being on the property of the agency, I authorize Kids & Horses, Inc. to:

1. Secure and retain medical treatment and transportation if needed.

2. Release client records upon request to the authorized individual

or agency involved with the medical treatment.

Consent Plan:

This authorization includes x-rays, surgeries, hospitalization, medication, and any treatment deemed "life-saving" by the physician. This provision will only be invoked if the person(s) above are unable to be reached.

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Non-Consent Plan:

I do not give my consent for emergency medical/aid treatment is required due to illness or injury during the process of receiving services, or being on the property of the agency. In the event that emergency treatment/aid is required, I wish the following procedures to take place:

Signature:

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Date: *

When are you available?

Adaptive riding is being offered Sundays, Mondays, Tuesdays, and Wednesdays. Hippotherapy is offered Tuesdays, Wednesdays, and Thursdays. Our Comprehensive Life Skills classes run on Fridays during the school year, and our Dementia program is on Saturdays.

Number of hours you are available (Example in ? box) * 🛈

Please provide any other information about yourself that might help us fully utilize your talents and interests and provide you with a rewarding volunteer experience. *

Signature: *

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Date: *

Volunteer Acknowledgement Form:

Volunteers are a very important part of our program, and as a volunteer it is equally important that you understand the policies and procedures at Kids & Horses Therapeutic Riding Center. Working together, we can make the program the best we can for the participants and everyone involved. As a volunteer, you play a crucial role in taking an active part in making the program a continued success.

By placing my signature at the bottom of this form, I acknowledge that I have read, understood, and will follow the policies and procedures of Kids & Horses program.

Signature: *

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Date: *