Equest Volunteer Application

Page 1 of 5


CONTACT INFORMATION
























MILITARY & FIRST-RESPONDER



Page 2 of 5

CONSENT for CRIMINAL BACKGROUND CHECK
I, the Applicant named above, hereby give my permission for Equest to obtain information relating to my criminal history record. The criminal history record, as received from the reporting agencies, may include arrest and conviction data, as well as plea bargains and deferred adjudications. I understand that this information will be used, in part, to determine my eligibility for employment or a volunteer position with Equest. I also understand that, as long as I remain an employee or a volunteer with Equest, the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history report and a procedure is available for clarification if I dispute the record as received. I, the Applicant named above, do, for myself, my heirs, executors, and administrators, hereby remise, release, and forever discharge and agree to indemnify and hold harmless Equest and each of their officers, directors, employees, and agents from and against any and all causes of action, suits, liabilities, costs, debts and sums of money, claims and demands whosoever, and any and all related attorneys' fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become an employee of, or volunteer for, Equest.

APPLICANT INFORMATION
All of the information below is required if you are over the age of 16.



Please note this does not say country.




Required for US residents if older than 18
CRIMINAL DISCLOSURE




Page 3 of 5

CONSENT for EMERGENCY MEDICAL TREATMENT
I, ______________________________________ (“Volunteer”), am over 18 years of age and fully competent to sign this Emergency Medical Form, which I have read and understand, or, if under age, Volunteer has obtained the signature of his/her parent/guardian, who, by such signature, represents he/she has read and understands this form. In case of medical emergency or necessity, “Volunteer” authorizes Equest to seek or provide for “Volunteer” such medical assistance as may be necessary or advisable and further authorizes Equest to seek the assistance of any physician or medical facility to provide any medical/surgical care, including, but not limited to, hospitalization, with such treatment to include anesthesia as necessary or advisable, that the physician or medical facility deems or determines to be necessary or advisable, pending receipt by the physician or medical facility of any other consent to treatment from or on behalf of “Volunteer” “Volunteer” understands that NO LIABILITY can be accepted by any of the organizations concerned, including Equest, in the event such accident may occur. In the event any provision of this form is determined to be unenforceable, all other provisions shall remain in full force and effect.

EMERGENCY CONTACT








Page 4 of 5

STATEMENT of UNDERSTANDING, AUTHORIZATION RELEASE and IDEMNITY
I, the undersigned ("Volunteer"), am over 18 years of age and fully competent to make this Statement of Understanding, Authorization, Release and Indemnity ("Statement"), which I have read and understand. I understand the information I have provided may be verified and permit Equest to inquire of others concerning my suitability as a volunteer. In the course of volunteering, I may deal with confidential information and agree to keep said information in the strictest confidence. The relationship between Equest and me is an "at will" arrangement and may be terminated at any time, without cause, by either Equest or me. I understand that, as a volunteer, I will assist in the riding and instruction of mentally or physically challenged riders, and that I will work with and around horses, as well as riders. I understand that I cannot serve as a volunteer until this Statement has been signed. 

In return for the opportunity to serve as a volunteer with Equest, I hereby forever release, acquit and discharge Equest and its officers, directors, trustees, agents, employees, representatives, affiliates, successors and assigns (collectively the "Released and Indemnified Parties") from any and all claims, demands and causes of action of any and every kind or nature, including those caused in whole or in part by the negligence of any of the Released and Indemnified Parties, which I may now or in the future have against any or all of the Released and Indemnified Parties and that arise in whole or in part as a result of my involvement with Equest. I also understand and agree that Equest assumes no liability for accidents or acts of negligence or gross negligence by anyone, including the Releases and Indemnified Parties. 

I further agree to fully indemnify and defend any of the Released and Indemnified Parties against any and all claims, demands or causes of action of any and every kind or nature (including attorney's fees and other defense costs), including those caused in whole or in part by the negligence of any or all of the Released and Indemnified Parties, which directly or indirectly relate to personal injuries or property damages sustained by me and that arise in whole or in part as a result of my involvement with Equest. If any provision of this Statement is determined to be unenforceable, all other provisions shall remain in full force and effect.

CONSENT for PHOTOGRAPHY
For valuable consideration given and which is hereby acknowledged, the Volunteer named above hereby grants to Equest permission to take, or have taken, still and moving photographs and films, including television pictures, of the Volunteer, and consents and authorizes Equest, its advertising agencies, news media, and any other persons interested in Equest and its work, to use and reproduce such photographs, films or pictures, and to circulate and publicize the same by all means, including, without limiting the generality of the foregoing, newspapers, television media, brochures, pamphlets, instructional materials, books, and clinical materials. 

With respect to the foregoing matters, no inducements or promises have been made to secure this signature to this release other than the intention of Equest to use, or cause to be used, such photographs, films, and pictures for the primary purpose of promoting Equest and its work.

CONFIDENTIALITY AGREEMENT
The undersigned volunteer of Equest Therapeutic Horsemanship acknowledges that in the course of volunteering, Volunteer may receive and have access to information and records of Equest clients, volunteers, and donors including but not limited to medical records, diagnosis, progress reports, and financial statements. 

The volunteer hereby agrees to hold such information in confidence and not to divulge the information to any person except as directed by Equest. Volunteers also further agrees that written materials in the cleint, volunteer or donor's files will be maintained in confidence and not removed from such files

SOCIAL MARKETING POLICY
In the area of social media (print, broadcast, digital, online), the following guidelines apply in the use of social media for our volunteers:
  1. Should you decide to create a personal blog or website, be sure to provide a clear disclaimer that the views expressed in the blog are the author’s alone and do not represent the views of Equest Therapeutic Horsemanship. 
  2. All information published on any volunteer blog should comply with Equest’s confidentiality policy. This also applies to comments posted on other social networking sites, blogs and forums. 
  3. Your online presence can reflect on Equest. Be aware that your comments, posts or actions captured via digital or film images can affect the image of Equest. 
  4. Do not use any Equest logos or trademarks without written consent.

Page 5 of 5

REFERRALS
Please list two non-family referrals.