Kids & Horses Therapeutic Riding Center A Non-Profit Organization   Volunteer/Staff Information Form and Health History   General Information:    
Name: *
 
Date: *
 
Address: *
 
City: *
 
State: *
 
Zip: *
 
Email: *
 
Date of Birth: *
 
Phone: (H) *
 
(W) *
 
(C) *
 
Employer/School: *
 
Address: *
 
Parent/Legal Guardian Name: *
 
Address: *
 
How did you learn about the program? *
 
 
 
 
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.
Item #22 *
 
 
 
 
 
Allergies: *
 
 
 
Medications: *
 
 
 
Check what areas you are interested in:
Program: *
 Horse Handling
 Sidewalking with a student
 Stable Management
 Facility Repairs
Special Events: *
 Horse Show
 Fundraising
 Special Olympics
 Trail Rides
Administration: *
 Public Relations
 Grant Writing
 Newsletter
 Volunteer recruitment
 Photo/Video
 Budget & Finance
 Future Planning
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: *
 
 
 
 
 
Date: *
 
Photo Release:
I *
 Do
 Do Not
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: *
 
 
 
 
 
Date: *
 
Background Information:
Have you ever been convicted of a crime? *
 Yes
 No
Please Explain: *
 
 
 
 
 
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: *
 
 
 
 
 
Date: *
 
CURRENT DRIVER'S LICENSE: *
 Yes
 No
License Number *
 
State: *
 
Confidentiality Agreement:
I understand that all information (written or verbal) about participants in this PATH center is confidential and will not be shared with anyone without the expressed and written consent of the participant and their parent/legal guardian in the case of a minor.
Signature: *
 
 
 
 
 
Date: *
 
Volunteer Liability Release:
As a volunteer at Kids & Horses Inc., I acknowledge the risk and the potential for risks of a horseback-riding program. However, I believe that the benefits to myself and the clients I work with are greater than the risk assumed. I, hereby, intending to be legally bound for myself, my heirs and assigns, my executors, or administrators, waive and release forever all claims for damages against Kids & Horses Inc., its Board of Directors, Instructors, Therapists, Volunteers and/or Employees for any and all injuries and/or losses I may sustain while participating in Kids & Horses Inc.'s program.
Signature (Volunteer/Staff): *
 
 
 
 
 
Date: *
 
Signature (Parent/Legal Guardian): *
 
 
 
 
 
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
Item #62 *
 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.
Consent Signature: *
 
 
 
 
 
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:
Item #85 *
 
 
 
 
 
Signature: *
 
 
 
 
 
Date: *
 
When are you available?    Adaptive riding is being offered Sundays, Mondays, Tuesdays, and Wednesdays. Hippotherapy is offered Tuesdays, Wednesdays, and Thursdays.
Item #89 *
 Sundays
 Mondays
 Tuesdays
 Wednesdays
 Thursdays
 Fridays
 Saturdays
Item #90 *
 AM
 PM
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: *
 
 
 
 
 
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: *
 
 
 
 
 
Date: *