HORSEPOWER | Volunteer Application Form

Step 1 of 12

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone Number

Work Phone Number

Cell Phone Number

Date of Birth

MM slash DD slash YYYY

Employer/School

Title

Spouse Information

Spouses Name

Employer

Title

Parents Information

Spouses Name

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Other Info

How did you learn about HORSEPOWER

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

Call

Text

Do you have horse experience:

None

Somewhat

Considerabl

Please briefly explain

Are you comfortable working around horses?

Yes

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

Yes

Health History

Physicians Name

Medical Facility

Health Ins Company

Health Ins. Company Phone

Policy

Medication

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

Emergency Contact Information

Name

First Last

Phone

Relationship

Second Contact

Name

First Last

Phone

Relationship

Consent and Liability Waivers

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(Required)

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

Date

MM slash DD slash YYYY

Confidentiality Agreement

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

MM slash DD slash YYYY

Photo Release

I Do

I 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

MM slash DD slash YYYY

Background Information

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

Yes

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

Yes

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)

Consent Signature

Date

MM slash DD slash YYYY

Drivers License

Current Drivers License?

Yes

If YES License Number

State

Signature

Consent Plan and Agreement

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 consent

I do not consent

Date

MM slash DD slash YYYY

Liability Release

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.

Signature

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

Date

MM slash DD slash YYYY

CAPTCHA

Volunteer Application Form

Spouse Information

Parents Information

Other Info

Health History

Emergency Contact Information

Second Contact

Consent and Liability Waivers

Confidentiality Agreement

Photo Release

Background Information

Drivers License

Consent Plan and Agreement

Liability Release

Volunteer Dress Code