Wendell’s Wish Therapeutic Riding Program of E.P.O.N.A.

Volunteer/Staff Information Form and Health History

� Volunteer � Staff

General Information

Full Name: ________________________________________________ Today’s Date: ____________________

Address: _____________________________________________________________ DOB: ________________

Phone (H): ___________________ Phone (W): ____________________ Phone (Cell): ____________________

E-Mail Address (H): ____________________________ E-Mail Address (W): _____________________________

Employer/School: ____________________________________________________________________________

Address: ___________________________________________________________________________________

If under 18, Parent/Legal Guardian Name(s): ______________________________________________________

Address (if different from yours): ________________________________________________________________

How did you learn about our program? ___________________________________________________________

Recent medical tests: Date of Last Tetanus Shot: ____________ Tuberculosis Test + -- Date: ____________

(Please consult your health care provider if you are not up to date with these shots/tests)

Health History

Please describe your current health status, particularly regarding the physical/emotional demands of

participating in an equine assisted program. Address fitness, cardiac, respiratory, bone/joint function,

recent hospitalizations/surgeries, or lifestyle changes.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Allergies: (medication, food, environmental) __________________________________________________

_________________________________________________________________________________________________

Medications: (prescribed, over-the-counter) __________________________________________________

_____________________________________________________________________________________

Volunteer - Check the area(s) in which you have interest:

� Horse Leader � Barn Chores � Administrative

� Side Walker � Equipment/Supply Maintenance � Fundraising Events/Exhibits

� Groomer/Tacker � Scrapbooking, Newsletter � Other ___________________

Please check the box(s) that apply to your availability:

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Morning
Afternoon
Evening

CPR Certification: Y N Expires: ____________________

First Aid Certification: Y N Expires: ____________________

Instructor Certification: Y N Expires: ____________________

Briefly describe your horse experience: ______________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

I understand that the information provided above is accurate to the best of my knowledge. I know of no reason

why I should not participate in Wendell’s Wish Therapeutic Riding Program.

Signature: ___________________________________________ Date: _____________________

(Volunteer/Staff)

PHOTO RELEASE:

I � DO � DO NOT consent to and authorize the use and reproduction by

Wendell’s Wish Therapeutic Riding Program of any and all photographs and/or audio/visual materials taken of

me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.

Signature: _______________________________________________ Date: __________________

(volunteer/staff)

Background Information

Have you ever been charged with or convicted of a crime? No Yes, please explain___________

____________________________________________________________________________________

____________________________________________________________________________________

I, ____________________________________(volunteer/staff), authorize Wendell’s Wish Therapeutic

Riding Program 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 violations of state or federal

criminal laws, including by not limited to convictions for crimes committed upon children and/or animals.

I understand that such access is for the purpose of considering my application as a volunteer or an

employee, and that I expressly DO NOT authorize Wendell’s Wish Therapeutic Riding Program, its

directors, officers, employees or other volunteer to disseminate this information in any way to any

other individual, group, agency, organization or corporation.

Signature: _______________________________________________ Date: __________________

(volunteer/staff)

CURRENT DRIVER’S LICENSE YES NO License #:_____________________ State ____

CONFIDENTIALITY AGREEMENT

I understand that all information (written and verbal) about the participants in Wendell’s Wish

Therapeutic Riding Program is confidential and will not be shared with anyone without the

express written consent of the participant and their parent/guardian in the case of a minor.

Signature: _______________________________________________ Date: __________________

(volunteer/staff)