VerdeViewEquestrianCenter

Volunteer Application

Contact Info:

Name: ______Date:______

Mailing Address: ______

Employer/School: ______

Date of Birth: ______Phone: (H) ______(c) ______

Email: ______

Parent/Guardian’s name, address & phone: ______

______

Background Info:

Please list the name and phone number of someone other than a family member who we may contact for a reference. ______

Have you ever been convicted of a crime? If yes, please explain ______

Health History:

Please describe your current health status, specifically regarding the physical and emotional demands of working in a therapeutic riding program. Please address fitness, cardiac, respiratory, bone or joint functions, recent hospitalizations or surgery, and mental and emotional stability.

______

______

Allergies: ______

Medications: ______

* Allergies to hay and horses are common, therefore we keep our hay in a separate building and can accommodate for those with these allergies.

Interests:

Verde View EC needs volunteers in a variety of capacities. Please circle the areas in which you are skilled and willing to share your gifts.

Programming / Administrative / Grounds
Grooming / Fundraising / Gardening
Leading / Marketing & PR / Trail Maintenance
Sidewalking / Newsletter / Stall Cleaning
Tacking / Data Entry / Facility repairs
Arts & Crafts / Special Events Planning / Carpentry

Please answer the following questions:

  1. Do you have any experience with horses? If yes, explain:
  1. Do you have experience working with children or adults with disabilities? If yes, please describe:
  1. What is your previous volunteer experience?
  1. What do you hope to gain from volunteering at Verde View?
  1. How did you hear about VerdeViewEquestrianCenter (i.e. Facebook, Friend, brochure, etc.)

Liability Release:

I would like to participate as a volunteer at VerdeViewEquestrianCenter. I acknowledge the risks of working with horses and horseback riding. However, I feel the possible benefits to myself are greater than the risks assumed. I hereby (for myself, my heirs and assigns, executors and administrators) waive and release forever all claims for damages against Verde View Equestrian Center, Inc., its Board of Directors, instructors, therapists, aides, volunteers and/or employees, Verde View Farm, Ray Healy, Lori Piccirilli, Marissa Piccirilli, for any and all injuries and losses I may sustain while participating in Verde View programs or events.

Volunteer Name (print): ______Date: ______

Volunteer Signature: ______

Parent/Guardian Name (if under 18): ______Date: ______

Parent/Guardian Signature (if under 18): ______

Relationship to volunteer: ______

Photo Release (optional):

I hereby consent to and authorize the use and reproduction by VerdeViewEquestrianCenter of any and all photographs and any other audiovisual materials taken of me for promotional printed material, educational activities, exhibitions, or for any other use for the benefit of the program.

Volunteer Signature: ______Date: ______

Parent/Guardian Signature: ______Date: ______

Confidentiality Agreement:

I agree to respect and observe privacy and confidentiality of the participants of VerdeViewEquestrianCenter and not to discuss or disclose any sensitive information about any person or their family.

Volunteer Signature: ______Date: ______

Authorization for Emergency Medical Treatment (please print):

Volunteer Name: ______Date: ______

Person to contact in case of emergency:______

Address & Phone Number of person to notify:______

In the event emergency medical aid/treatment is required due to illness or injury during involvement with VerdeViewEquestrianCenter or while on the property of the organization, I authorize VerdeViewEquestrianCenter to:

a)Secure and retain medical and transportation if needed

b)Release records upon request to the authorized individual or agency involved in the medical emergency treatment

c)If an option is available, which hospital would you prefer to be taken to in the case of an emergency? ______

This authorization includes x-rays, surgery, hospitalization, medication and any treatment or procedure deemed “life-saving” by the attending physician.

Volunteer Signature: ______

(If volunteer is a minor parent/guardian signature required)

Relationship to volunteer: ______Date: ______