Loudoun Therapeutic Riding 2021 Volunteer Application

General Information

First Name

Last Name

Birthdate (MM/DD/YYYY)

Gender identity

MaleFemaleGenderqueer/Non-binary

Height

Weight

Primary Contact Phone

Cellular Phone

Primary Contact Email

Address Line 1

Address Line 2

City

State

Postal Code

Your school or university: Enter N/A if not in school.

Your employer:

How did you hear about LTR?

Please tell us specifics of how you heard about LTR, i.e. name of friend/family, name of event, social media type, search engine, etc..

Parent/Guardian Information (**REQUIRED if volunteer is under the age of 18)

Mother/guardian name (First Last):

Father/guardian name (First Last):

Phone

If different from above: Address Line 1

Address Line 2

City

State

Postal Code

Please indicate areas of interest or expertise. (press and hold Ctrl key for multiple choices)

Emergency Contact Name:

Emergency Contact Phone Number:

Please describe any previous riding experience.

Medical

Date of last Tetanus shot:

Tuberculosis Test - Date (MM/DD/YYYY)

Tuberculosis Test Result:

Please describe your current health status, particularly regarding the physical/emotional demands of working at a center providing equine-assisted activities/therapies (EAA/T). Address recent hospitalizations/surgeries, lifestyle changes, and fitness including cardiac, respiratory, and bone or joint function.

Allergies (include allergies to medications):

Medications:

Physician's Name:

Preferred Medical Facility:

Do you have health insurance coverage? Coverage required to volunteer.

NoYes

Health Insurance Company:

Policy #:

Releases/Authorizations/Waivers

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

If Yes, please explain.

I authorize Loudoun Therapeutic Riding Foundation, Inc. (LTRF) to receive information from any law enforcement agency, including police departments and sheriff’s departments, of the 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.

I understand that such access is for the purpose of considering my application as a Volunteer/Staff Member in LTRF’s program and that I expressly DO NOT authorize LTRF, its directors, officers, employees, or other volunteers to disseminate this information in any way to any other individual, group, agency, organization, or corporation.

Current Driver's License:

License #:

State:

Photo release:

First Name

Last Name

PHOTO RELEASE: Consent to and authorize the use and reproduction by Loudoun Therapeutic Riding Foundation, Inc. of any and all photographs and any other audio/visual materials taken of me and/or my child for promotional material, social media, educational activities, exhibitions or for any other use for the benefit of the program.

I do consentI do not consent

Date (MM/DD/YYYY)

Signature: (Type name to sign photo release. Parent/guardian if under the age of 18)

I, ( enter name of Participant (Volunteer) unless under the age of 18 or under a legal disability otherwise enter name of Parent/Guardian.

Liability Release and Waiver of Right to Sue

I, __________________________________________________ give this release and waiver of right to sue (the "Release") in consideration for the opportunity to: (i) volunteer; (ii) take lessons; (iii) receive therapy; (iv) visit, handle, ride or be in proximity to horses; and/or (v) engage in any other Equine Activity at the property (“Property”) owned by Loudoun Therapeutic Riding Foundation, Inc., a Virginia not for profit corporation (“LTR”). Capitalized terms not defined in this Release shall have the meaning defined in Virginia’s Equine Activity Liability Act (Code of Virginia Sec. 3.2-6200 et seq.) (the "Act") which is incorporated by this reference. In this Release use of the term "Released Parties" shall be defined to include LTR, as well as its directors, officers, employees, volunteers, agents, successors, assigns and insurers.

The Act defines Equine Activities and I understand and hereby acknowledge and agree that when I am on the Property I am a Participant in an Equine Activity. The Act also describes certain Intrinsic Dangers of Equine Activities (the “Intrinsic Dangers”). Those Intrinsic Dangers include: (i) the propensity of equines to behave in ways that may result in injury, harm or death to persons on or around them; (ii) the unpredictability of an equine's reaction to such things as sounds, sudden movement, and unfamiliar objects, persons, or other animals; (iii) certain hazards such as surface and subsurface conditions; (iv) collisions with other animals or objects; and (v) the potential of a Participant acting in a negligent manner that may contribute to injury to the Participant or others, such as failing to maintain control over the equine or not acting within the Participant’s ability.

I understand and hereby acknowledge and agree that LTR, its directors, officers, employees, volunteers and agents are Equine Activity Sponsors and/or Equine Professionals as defined by the Act and that the Act provides that such Sponsors and Professionals are not liable for injury or death resulting from the Intrinsic Dangers. I understand that, as a Participant, the Act allows me to waive my right to sue for any potential injury or death resulting from the Intrinsic Dangers. The Act allows this Release to be binding in certain circumstances even if the Equine Activity Sponsor or Professional has committed an act or omission that constitutes negligence for my safety.

Because I desire to participate in Equine Activities I hereby agree that I understand the Intrinsic Dangers and I agree to assume all of the risks posed by the Intrinsic Dangers and I release and waive all claims and rights to sue, including without limitation claims for negligence, which I or my family members, estate, heirs, personal representatives, successors and assigns may now or hereafter have against the Released Parties for my death or personal injury as a result of participating in Equine Activities.

If the Participant is a minor or otherwise under a legal disability, this Release shall be executed by the Participant’s parents, legal guardian or their duly authorized representative. By signing, the parents or guardian agrees to waive the parents’ or guardian’s and Participant's rights to sue the Released Parties and also assumes on behalf of the parents, guardian and Participant the Intrinsic Dangers and all other risks of Equine Activities; and agrees to hold harmless and indemnify the Released Parties against any and all payments, claims, damages, liabilities, suits, losses and expenses, including attorneys fees and costs, for any accident, damage, loss, injury, illness or death caused to Participant or to Participant’s property. The person or persons signing on behalf of a Participant hereby warrant and represent that they are duly authorized to grant this Release and will indemnify and hold harmless the Released Parties against any claims against the Released Parties by another parent or other non-signing party.

I intend for this Release to be interpreted so as to afford the Released Parties the maximum protection against liability possible under the Act and other provisions of Virginia law. If any provision in this Release, or any portion thereof, is held to be invalid, that fact shall not affect the validity of the remaining provisions and portions thereof.

I have read and understand this Release and the rights I am giving up and I agree to be bound by this Release on an ongoing basis. I agree that I may not revoke this Release for conduct that occurred prior to my revocation, and that I can only revoke this Release on a prospective basis by delivering a written revocation to LTR’s Executive Director.

Volunteer's Signature: Type name to sign Liability Release & Waiver of Right to Sue.

Signature: 1-Parent/Guardian - Type name to sign Liability Release & Waiver of Right to Sue (enter N/A if Volunteer is over 18 y.o. and not under a legal disability).

Signature: 2-Parent/Guardian - Type name to sign Liability Release & Waiver of Right to Sue (enter N/A if Volunteer is over 18 y.o. and not under a legal disability).

Date (MM/DD/YYYY)

Confidentiality Statement (applicable to volunteers, staff, Board of Directors, other)

§ As a volunteer/staff member/director/workshop participant at LTRF, I am a valuable member of the center community.

§ I have received and read the Center Information Manual/Volunteer Handbook and Program Policies including confidentiality policy and emergency procedures.

§ I understand and agree that I must hold confidential any personal or medical information regarding participants and/or families, and/or any LTR business information and interests.

§ I agree to abide by all program policies and rules.

§ I may be permanently removed from center activities if I fail to adhere to center policies and rules established for participation.

I agree to adhere to all policies, procedures, & rules established by LTR for participation in center programs & activities. Digital Signature: (Type name below to sign if over 18 years of age)

Date (MM/DD/YYYY)

Volunteer Availability: Please indicate day(s)/time(s) preference below.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Next Steps:

Thank you for completing the required application/annual update of your information! You will now be redirected back to our website. We appreciate your support and look forward to seeing you soon. Our Volunteer Coordinator will contact you regarding the schedule once it has been determined.

Please check your spam/junk folders for LTR replies!

Contact Information