Reining Strength Volunteer & Staff Information Form & Health History

Reining Strength Volunteer & Staff
Information Form & Health History

Contact Information

First Name

Last Name

Street Address

City

State

Zip Code

Personal Email

Birthdate

01/01/2000

Cell Phone

Home Phone

Work Phone

Preferred Phone

Employer

Title

How did you hear about us?

Areas of Interest

Days & Times Available

Availability Details

Health Status

Allergies

Background Information

Have you been convicted of crime?

If yes, please explain

I authorize Reining Strength Therapeutic Horsemanship 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 but not limited to convictions for crimes committed upon children or animals.

I understand that such access is for the purpose of considering my application as an employee/volunteer, and I expressly DO NOT authorize Reining Strength, its directors, officers, employees or other volunteers to disseminate this information in any way to any other individual, group, agency, organization or corporation.

Drivers License Number

Signature

Date

The Volunteer Coordinator will contact you to obtain your Social Security Number for the background check. For your privacy your SSN will be used only to complete the background check and will be destroyed afterwards.

Authorization for Emergency Medical Treatment

Complete Legal Name

Date of Birth

Physician Name

Medical Office/Facility

Health Insurance Company

Insurance Status

Current Medications

Allergies(medications/food/other)

Do you have any physical limitations?

Emergency Contact Information

#1 Name

Home Phone

Cell Phone

Work Phone

#2 Name

Home Phone

Cell Phone

Work Phone

#3 Name

Home Phone

Cell Phone

Work Phone

Medical Treatment Consent

In the event that emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on Reining Strength Therapeutic Horsemanship property, I authorize Reining Strength Therapeutic Horsemanship, to:

1. Secure and retain medical treatment and transportation if needed.

2. Release client/participant’s 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 physicians. This provision will only be invoked if none of the Emergency Contacts listed above can be reached.

By entering my name below I agree the medical treatment statement above.

Date

Orientation and Confidentiality

I will attend an orientation at Reining Strength Therapeutic Horsemanship (RSTH) and have an understanding of the information provided, will demonstrate the procedures pertaining to volunteering, and have received and read or will read a copy of the RSTH volunteer manual. I also have been made aware of RSTH’s confidentiality policy and understand that the any information that I have become privy to about a client during my time as a volunteer shall remain confidential. The consequences of violating RSTH’s confidentiality and privacy policy may include removal from the program.

By entering my name below I agree to the Confidentiality policy statement above.

Date

Photo Release

I consent to and authorizeI do NOT consent to

For valuable consideration given and which is hereby acknowledged, the undersigned hereby grants to Reining Strength Therapeutic Horsemanship permission to take, or have taken, still and moving photographs and films of the above named individual, including television pictures, and consents and authorizes Reining Strength Therapeutic Horsemanship, its advertising agencies, news media, and any other persons interested in Reining Strength Therapeutic Horsemanship and its work, to use and reproduce the 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. Please note that your presence or participation in a public event at Reining Strength Therapeutic Horsemanship or event involving Reining Strength Therapeutic Horsemanship constitutes a tacit waiver of this non-consent. Electing the non-consent option will not necessarily prevent a subject from being photographed or filmed at any such event by Reining Strength Therapeutic Horsemanship or the general public. 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 Reining Strength Therapeutic Horsemanship to use, or cause to be used, such photographs, films, and pictures for the primary purpose of promoting Reining Strength Therapeutic Horsemanship and its work.

Volunteer's Name

By entering my name below I agree the photo release statement above.

Date

Liability Release

the undersigned adult as volunteer, or parent or guardian of

, a minor, would like to volunteer at Reining Strength Therapeutic Horsemanship.

I acknowledge the risks and potential for risks of equine activities. I understand that I/my son/daughter/ward, will be working with and around horses, as well as, riding horses at Reining Strength Therapeutic Horsemanship. However, I feel that the possible benefits to myself/son/daughter/ward are greater than the risk assumed. I, the undersigned client and/or parent or guardian, hereby, intending to be legally bound, for myself, my heirs, and assigns, executors or administrator, waive and forever release, acquit, discharge and hold harmless all claims for damages against Reining Strength, its board of directors, trustees agents, instructors, therapists, employees, representatives, volunteers, owners of property on which Reining Strength Therapeutic Horsemanship operates, successors or assigns on account of any personal injuries and/or personal damages known or unknown, or in any way growing out of, the acts of Reining Strength Therapeutic Horsemanship, its board of directors, trustees, agents, instructors, therapists, employees, representatives, volunteers, owners of the property on which Reining Strength Therapeutic Horsemanship operates, successors or assigns.

By entering my name below I understand that under TEXAS LAW (CHAPTER 87, CIVIL PRACTICE AND REMEDIES CODE), A FARM ANIMAL PROFESSIONAL OR FARM OWNER OR LESSEE IS NOT LIABLE FOR
AN INJURY TO OR THE DEATH OF A PARTICIPANT IN FARM ANIMAL ACTIVITIES, INCLUDING AN EMPLOYEE OR INDEPENDENT CONTRACTOR, RESULTING FROM THE INHERENT RISKS OF FARM ANIMAL ACTIVITIES.

Date

Contact Information