VOLUNTEER APPLICATION

EMERGENCY MEDICAL TREATMENT
Name
Date of Birth

MonthDayYear
Date
Parent or Guardian (if under 18)
Emergency Contact
Relationship
Phone
Emergency Contact
Relationship
Phone
Medical conditions requiring special consideration/treatment
Allergies
Current medications & dosage
Consent Plan

In the event emergency medical aid/treatment is required due to illness or injury during the process of volunteering, or while being on the property of the agency, I authorize Horse Heritage Educational Program to: Secure and retain medical treatment and transportation if needed. And Release volunteer records upon request to the authorized individual or agency involved in 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) above is unable to be reached.
Consent Signature

Clear
Parent Signature (if under 18)

Clear
Parent Name Printed
Date

MonthDayYear
Date

Risk Management Statements: Check if understood

	Understood
I understand that I cannot smoke while on the property of Horse Heritage.
I understand Horse Heritage has designated business hours at which time staff are present on the property.
I understand that I must wear an approved ASTM/SEI riding helmet to ride any horse.
I understand that horses are not to be fed anything by hand. Hand feeding encourages biting and nipping.
I understand that horses are unpredictable. They may kick, bite or step on me.

Signature of Volunteer (if volunteer is under the age of 18. Parent/Guardian must sign)

Clear
Date

MonthDayYear
Date

PHOTO RELEASE
I consent to and authorize the use and reproduction by Horse Heritage Educational Program 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. I further consent that my name may be revealed therein or by descriptive text or commentary.
Signature of Volunteer (if volunteer is under the age of 18. Parent/Guardian must sign)

Clear
Date

MonthDayYear
Date

CONFIDENTIALITY AGREEMENT
I understand that all information (written and verbal) about participants at Horse Heritage Educational Program is confidential and will not be shared with anyone without the expressed written consent of the participant and their parent/guardian in the case of a minor.
Signature of Volunteer (if volunteer is under the age of 18, Parent/Guardian must sign)

Clear
Date

MonthDayYear
Date

WAIVER OF LIABILITY
- I, the undersigned, in full recognition of the possible dangers and hazards inherent in any activity involving horses, do hereby agree to assume all the risks and responsibilities surrounding my participation in programs using Horse Heritage Educational Program horses and horse facilities; and further hereby defend, hold harmless, indemnify and release and forever discharge Horse Heritage Educational Program, and its staff members, from and against any and all claims, demands and actions on account of damage to personal property, injury, or death, which may result from my child's participation in programs utilizing Horse Heritage Educational Program's horses and horse facilities, which result from causes beyond the control of and without the fault or negligence of Horse Heritage Educational Program, or its employees/volunteers, during the period of my participation in the aforementioned program.
- All volunteers and staff are required to wear approved equestrian helmets. If you do not have an ASTM/SEI approved helmet, Horse Heritage Educational Program will provide one to you for the program activities.
- Under Washington law, an equine activity sponsor or and equine professional shall notbe liable for an injury to or death of a participant engaged in an equine activity. RCWA 4.24.530
Signature of Volunteer

Clear
Date

MonthDayYear
Date
Printed Name of Volunteer
Parent/Guardian Signature

Clear
Printed Name of Parent/Guardian
Date

MonthDayYear
Date

Horse Heritage Educational Program