HORSEPOWER Volunteer form

First Name

Middle I.

Last Name

Address

Street address

Street Address Line 2

City State

Zip

Home Phone Number

Please enter a valid phone number.

Cell Number

Please enter a valid phone number.

Work Number

Please enter a valid phone number.

E-mail

example@example.com

Date of Birth

Date

Employer/School

Title

ex. Student

Spouse's Name

(If applicable)

Spouse Employer

(If applicable)

Spouse Title

(If applicable)

Parent(s)/ Legal Guardian Name

(If under the age of 18)

Parent/Guardian Phone Number

Please enter a valid phone number.

Parent/ Guardian Address (if not same)

Address

Street Address Line 2

City State

(Zip

How did you learn about HORSEPOWER?

How would you like to be contacted (check all that apply):

CallTextEmail

Do you have horse experience:

NoneSomewhatConsiderable

Briefly explain horse experience?

Are you comfortable working around horses?

yesno

Are you able to walk for 45 minutes and jog short distances in the dirt?

yesno

HEALTH HISTORY

Physicians Name

Medical Facility

Health Ins. Company

Policy #

Allergies

Medication

Health History (Fitness, Respiratory, bone & joint function. recent surgery)

In the event of an emergency, Please contact:

Name

Phone

Relationship

Name

Phone

Relationship

To Make sure that all below consent and liability waivers are signed. All volunteers and independent contractors must have these forms signed before participating in the Volunteer Orientation. I UNDERSTAND that the information provided above is accurate to the best of my knowledge. I know no reason why I should not participate in HORSEPOWER Inc.'s program. (If volunteer is under age of 18 years old this must be signed by a legal guardian)

Clear

Date

Confidentiality Agreement: While volunteering or working at Horsepower you may learn facts about our riders that areconsidered confidential. By signing this form, you agree to keep those facts confidential. Confidential means that you are free to talk about Horsepower and about your program and your experiences, but you are not permitted to disclose clients' names or talk about them in ways that will make their identity known.

Confidentiality Signature (If volunteer is under age of 18 years old this must be signed by a legal guardian)

Clear

Date

Photo Release

I doI do not

Consent to and authorize the use and reproduction by HORSEPOWER Inc. of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions, or for any other use for the benefit of the program.

Photo Release Signature (If volunteer is under age of 18 years old this must be signed by a legal guardian)

Clear

Date

Background Information:

Have you ever been charged with or convicted of a crime?

YesNo

Are you seeking Court Appointed, Lawyer recommended, or Community Service hours?

YesNo

If YES to either, please explain

(Last 2 questions)

I enter name authorize HORSEPOWER Inc. to receive information from any law enforcement agency. including police departments and sheriff's departments, 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 laws, including but not limited to convictions for crimes committed upon children. I understand that such access is for the purpose of considering my application as a volunteer, and that I expressly DO NOT authorize HORSEPOWER Inc., its directors, officers, employees, or other volunteers to disseminate this information in any way to any other individual, group, agency, organization, or corporation.

Date

Signature (If volunteer is under age of 18 years old this must be signed by a legal guardian)

Clear

Current Drivers License?

YesNo

If YES. License #

State

Consent Plan and Agreement In the event emergency medical aid/treatment is required due to illness or injury while being on the property of the agency. I authorize HORSEPOWER Inc. to: Secure and retain medical treatment and transportation as needed and 2: Release records upon request to the authorized individual or agency involved in the medical emergency treatment. This authorization includes, x-ray, surgery, hospitalization, medication, and any treatment procedure deemed "life saving" by the physician. This provision will only be invoked if the person(s) listed as your emergency contact is/are unable to be reached. (please check below):

Consent Plan and Agreement

I doI do NOT consent

Signature (If volunteer is under age of 18 years old this must be signed by a legal guardian)

Clear

Date

Liability Release As a volunteer doing work at HORSEPOWER Inc., I acknowledge the risks and potential for risks of a horseback riding program. however, I feel that the possible benefits to me and the clients with whom I work are greater than the risks assumed.I hereby, intending to be legally bound for myself, my heirs and assigns, executors, or administrators, and the company and its employees (if I am an independent contractor) waive and release forever all claims for damages against HORSEPOWER 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 HORSEPOWER Inc. program or while doing work for HORSEPOWER Inc.

Date

Consent Signature (If volunteer is under age of 18 years old this must be signed by a legal guardian)

Clear

HORSEPOWER Therapeutic Learning Center

4537 Walpole Rd, High Point. NC 27265

volunteer@horsepower.org

www.horsepower.org

336-931-1424

* By clicking "Submit" I agree my electronic signature and initials have the same force and effect as my written signature or initial.