Everybody Rides, Inc.
Volunteer Application Form
Date: ___/___/___
Name:_____________________________________________Age:___________
DOB:___/___/___
Address:
_________________________________________City:___________________Zip__________
Home Phone:________________________________ Cell Phone:______________________________
Email Address:
_______________________________________________________________________
Employer/School:____________________________ Best Time to Reach You:____________________
Parent/Legal guardian
Name:____________________________________ Relationship:_____________
Emergency Contact Name:
_____________________________________Relationship:______________
Phone:_________________(Cell)__________________(Work)
___________________(Home)
Please describe any previous equestrian experience:
Please describe any previous therapeutic riding experience:
Please describe any previous work (paid or volunteer) with
individuals with disability:
Can you walk for an hour and jog short distances? Yes_____ No_____
If no, please explain:
Please check areas you are interested in volunteering:
Lesson Program Administration
_____Horse Handler _____Board Member
_____Sidewalker with student _____Finance Committee
_____Lesson substitute _____Public Relations
_____Clerical
Special Events Fundraising
_____Horse Shows _____Chair Event
_____Special Olympics _____Host Event
_____ CommunityTeam Member
Please describe any other special skills that you would like
to share:
Release
and Hold Harmless
As a volunteer at Everybody
Rides, I acknowledge the inherent risks associated with working with or near
horses. I hereby release, aquit, and discharge the instructors, officers,
directors, employees, and volunteers from any claim for damage or suit by
reason of any injury, illness, or damage to persons or property during the
course of Everybody Rides activities, including transportation to and from the
activities. I hereby covenant that on my behalf not to file a claim or birng a
suit with respect to any such injury, illness, or death.
Signature of
volunteer:________________________________________ Date:___/___/___
Signature of parent/guardian if volunteer is under age 18:
_______________________________________________
Relationship:________________
Background Information
Have you ever been charged or convicted of a crime? If yes, please explain:
I, the undersigned, authorize Everybody Rides, to receive
information from any law enforcement agency pertaining to the convictions I may
have had for violations of state or federal criminal laws, including but not
limited to 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 the center,
its directors, officers, employees, or other volunteers to disseminate this
information in any way to any other individual, group, agency, organization, or
corporation.
Signature_______________________________________________________
Date:___/____/____
Current driver’s license #______________________________
State_______ Exp. Date:__________
Photo Release
I do ____ I do
not___
consent to and authorize the use and reproduction by
Everybody Rides of any and all photographs and any other audiovisual materials
taken on me for promotional material, educational activities, exhibitions or
for any other use for the benefit of the program.
Signature________________________________________________________
Date:___/___/___
Confidentiality
I understand that I amy be made aware of confidential
information regarding rider diagnosis, etc. I understand that under no
circumstances shall this informaion be shared with individuals external to
Everybody Rides and that information is provided solely for the purposes of
improving the therapeutic benefit to the Participant (s) participating in
equine assisted activity and therapy.
Signature_________________________________________________________
Date:___/___/___
Emergency Medical Information
Physician’s
Name:_______________________________________
Phone:__________________
Preferred Medical
Facility:_______________________________________________
Health Insurance Company:___________________________ Policy #:______________________
Allergies:_______________________________________________________________________
Current
Medications:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
AVAILABILITY
Please indicate your
volunteer availability. Please check all times that you may be available.
Checking all options adds flexibility to the schedule and does not mean that
you would volunteer at all of those times.
Your actual volunteer schedule will be arranged with the Volunteer Manager
following your training and orientation session. All lesson scheduling will be done via email.
Therapeutic
Riding Sessions
(thirty minute semi-private lesson x 6 weeks)
(Please indicate
preference #1-4; #1 = first preference)
_____April 6 – May
14
_____June 1 – July
16
_____Aug 3 – Sept 17
_____Oct 5 – Nov 19
Please indicate availability (circle all
that apply):
Wednesday Saturday
3:30p-5:30p
8:30a-10:30a
5:00p-7:00p
10:00a-12:00
Can we place your name on a sub list? Yes
No
***Please plan to arrive 15 minutes prior to scheduled
time***
Therapeutic Riding Sessions will be held at:
Hillrise Equestrian Center
1624 Walworth-Penfield Rd
Walworth NY
PLEASE RETURN THIS APPLICATION TO:
Everybody Rides, Inc.
PO Box 86
Clyde, NY 14433