Volunteer Medical Release & Risk Acknowledgment

Volunteer Medical Release & Risk Acknowledgment
PURPOSE

This medical release form must be completed, signed, and submitted before returning to volunteer activities at Henry’s Home, Horse, and Human Sanctuary. It outlines the potential risks of volunteering, particularly considering this facility's challenging environment and physical demands.

Acknowledgment of Risks

It is acknowledged and understood the following risks associated with volunteering at Henry’s Home, Horse, and Human Sanctuary:
1. Rough and Uneven Terrain
  The ranch has diverse, rough terrain. Walking in these areas can cause slips, trips, or falls, which could exacerbate existing injuries or cause new harm.
  Interaction with Horses
2. The ranch houses 27 horses. While the horses are well-cared for, they are large and unpredictable animals. Risks include accidental injury, such as being stepped on, shoved, or otherwise harmed due to direct interactions.
3. Physical Demands of Activities
  Volunteer work, such as lifting feed, carrying buckets, leading horses, or moving them into stalls, requires significant physical exertion. These activities may pose risks for individuals with pre-existing conditions or those recovering from injuries.
4. Prohibition of Pain Medication Use
  Volunteers are not permitted on the property if they use pain medication that may impair judgment, reflexes, or mobility. This restriction is necessary to ensure the safety of the volunteer and others.
Range of Volunteer Activities

The volunteer may perform the following activities upon returning to the ranch. Medical approval is required to participate in any volunteer activities:
- Feeding horses (e.g., carrying hay or filling feeding buckets)
- Leading horses
- Moving horses into stalls
- Overseeing the feeding process
If any restrictions or modifications to these activities are medically advised, the physician’s remarks below must reflect them.

PHYSICIAN INFORMATION

The attending physician must complete and sign this section to confirm the volunteer's capability to safely engage in permitted activities at Henry’s Home, Horse and Human Sanctuary.
Physician*

First NameLast Name
Medical Facility or Practice Name*
Cell phone number*
Please enter a valid phone number.
Email*
example@example.com
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EXAMINING PHYSICIAN:

I, the undersigned medical doctor, am familiar with the volunteer’s medical history and current health status. Based on my evaluation, I confirm the following (please check as appropriate):
Type of Incident or Concern (Check all that apply):*

The volunteer is physically fit to engage in all listed activities safely.The volunteer is fit but requires modified duties as follows (please describe):The volunteer is not currently fit to engage in volunteer activities.This volunteer is not currently prescribed any pain medication.
Physician's Remarks
Date of Incident or Concern*

MonthDayYear
Attached document as required

Cancelof
I have reviewed the risks and demands of these activities and verified that the volunteer’s current medical condition informs the above recommendations.
Consent*

By checking this box, I agree to use an electronic signature for this agreement, and I confirm it is an electronic representation of my signature for purposes of this form.
Signature*
By signing, I acknowledge that I have read and understand and voluntarily agree to this waiver and release. Just type your initials.
Date of signature*

MonthDayYear
By providing your email address, you are opting in to receive communications from Henry’s Home. You may opt out at any time.

VOLUNTEER CONSENT & RELEASE OF LIABILITY
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
I, {name}, certify that I have reviewed and understood the risks mentioned above. I acknowledge that I am not under the influence of any pain medications at the time of signing this agreement. I voluntarily engage in the permitted activities at Henry’s Home, Horse, and Human Sanctuary. I agree to waive all liability claims against the sanctuary, its staff, volunteers, and associates for any injuries or harm that may result from participation in these activities.
Consent*

By checking this box, I agree to use an electronic signature for this agreement, and I confirm it is an electronic representation of my signature for purposes of this form.
Signature*
By signing, I acknowledge that I have read and understand and voluntarily agree to this waiver and release. Just type your initials.
Date of signature*

MonthDayYear
EMERGENCY CONTACT INFORMATION
Name*

First NameLast Name
Relationship to Volunteer:*
Phone Number*
Please enter a valid phone number.
This document must be completed and submitted to Henry’s Home Horse and Human Sanctuary management before resuming volunteer activities or being onsite as a visitor. If you have any questions, please contact our team directly.
Should be Empty:

Volunteer Medical Release & Risk Acknowledgment

PHYSICIAN INFORMATION

EXAMINING PHYSICIAN:

I have reviewed the risks and demands of these activities and verified that the volunteer’s current medical condition informs the above recommendations.

VOLUNTEER CONSENT & RELEASE OF LIABILITY

EMERGENCY CONTACT INFORMATION