Vol Info Form updated -Jan 2022

Name*

First NameLast Name

Address

Street address

Street Address Line 2

CityState

Zip

Home Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Date of Birth

Date

Employer/School

Title

Spouses Name

Employer

Title

Parents Legal Guardian Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address Line 2

CityState

Zip

How did you learn about HORSEPOWER

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

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

CallTextEmail

Do you have horse experience:

NoneSomewhatConsiderable

Please briefly explain

Are you comfortable working around horses?

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

Physicians Name

Medical Facility

Health Ins. Company

Format: (000) 000-0000.

Health Ins Company

Policy

Allergies

Medication

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

In the event of an emergency, Please contact:

Name

Relationship

Format: (000) 000-0000.

Relationship

Name

Phone

Format: (000) 000-0000.

Relationship

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.

Signature*

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

Date*

Date

Confidentiality Agreement: While volunteering or working at Horsepower you may learn facts about our riders that are considered 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.

Signature*

Date*

Date

Photo Release ( please check):

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.

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

Signature

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, explain:

I ______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 violationsof 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.

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

State your name

Consent Signature

Date

Current Drivers License?

YesNo

If YES License

State

Signature

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

I do consentI do not consent

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.'s program or while doing work for HORSEPOWER Inc.

Consent Signature

Date

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

HORSEPOWER Therapeutic Learning Center

4537 Walpole Rd, High Point, NC 27265

www.horsepower.org

336-931-1424

HEALTH HISTORY