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)

Release, Waiver & Indemnity Agreement: The undersigned (hereinafter referred to as “Rider”), being of legal age or signing in conjunction with a parent or legal guardian if not of legal age, desires to enter upon the premises known as the Morven Park Equestrian Center and/or to use horses and/or facilities either owned or controlled by Loudoun Therapeutic Riding Foundation, Inc. (LTRF), and/or to receive training or instruction from the agents, volunteers , or employees of LTRF, and being fully aware of the risk of injuries and dangers inherent in entering upon said premises and/or the riding and handling of horses, hereby elects voluntarily to enter upon said premises and/or to participate in said activities, and does hereby willingly enter into this Release, Waiver & Indemnity Agreement (“Agreement”). Therefore, in consideration of being permitted to enter upon the premises known as Morven Park Equestrian Center and/or receive instruction or assistance from the agents, volunteers, or employees of LTRF, Rider knowingly and expressly agrees not to sue and to hold harmless and indemnify LTRF, and all of its agents, directors, officers, shareholders, employees, volunteers, consultants, partners, successors and assigns from and against any and all payments, claims, damages, liabilities, suits, losses and expenses, including attorney’s fees and costs, for any accident, damage, loss, injury, illness or death caused to Rider or to Rider’s property, and Rider agrees to assume all risks in riding or otherwise coming in contact with horses, including, without limitation, the risks of accident, damage, loss, injury, illness or death to Rider or to Rider’s property. Rider acknowledges that Rider has been given notice of the risks inherent in and intrinsic dangers of equine activities including (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 movements, and unfamiliar objects, persons, or another animals; (iii) certain hazards such as surface and subsurface conditions; (iv) collisions with other animals or objects; and (v) the potential for 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. Rider expressly agrees to assume all such risks. This Agreement shall specifically apply to Rider and if the Rider is under the legal age then to Rider’s parent or legal guardian. Further, pursuant to Virginia Code Section 3.2-6202, Rider (or if the Rider is under the legal age then Rider’s parent or legal guardian) knowingly and expressly waives his or her right to sue and agrees to assume all the risks specifically listed in the prior paragraph. If Rider is a minor or otherwise under a legal disability, this Agreement shall be executed by Rider’s parent or legal guardian. By signing, the parent or legal guardian agrees (i) to waive the parents, guardians, and Rider’s rights to sue the parties named in the immediately preceding paragraph; (ii) to assume, on behalf of the parent, guardian, and Rider, the risks set forth in the immediately preceding paragraph, in addition to all other risks of riding or otherwise coming into contact with horses; and (iii) to hold harmless and indemnify LTRF, and all of its agents, directors, officers, shareholders, employees, volunteers, consultants, partners, successors and assigns from and against any and all payments, claims, damages, liabilities, suits, losses and expenses, including attorney’s fees and costs, for any accident, damage, loss, injury, illness or death caused to Rider or to Rider’s property, and Rider agrees to assume all risks in riding or otherwise coming in contact with horses, including, without limitation, the risks of accident, damage, loss, injury, illness or death to Rider or to Rider’s property. It is expressly agreed by Rider and any parent or guardian whose signature appears on this document that this Agreement shall be governed and construed as being sufficient to satisfy the assumption of risk and waiver requirements necessary to relieve equine activity sponsors and equine professionals from liability under the Virginia Equine Liability Act (Virginia Code Section 3.2-6200 et seq.), and that LTRF, and all of its agents, directors, officers, shareholders, employees, volunteers, consultants, partners, successor and assigns are covered by the provisions of the Virginia Equine Liability Act (Virginia Code Section 3.2-6200 et seq.). This Agreement shall be governed and construed by the laws of the Commonwealth of Virginia, regardless of where any accident, damage, loss, injury, illness or death shall occur. In the event that any portion of this Agreement shall be declared unenforceable, such declaration shall not affect the remaining terms of this Agreement, which shall survive intact. Rider has been advised to wear protective headgear and hard-soled shoes; heeled footwear at all times while riding or otherwise coming in contact with horses, and expressly assumes the risk of injury resulting from the failure to do so and/or from selecting headgear or footwear which does not adequately protect against injury. Caution: Read before signing. Signature: Type your name below to agree and sign (*Parent/Guardian if under 18 years of age.):

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)

Digital Signature: - (If the volunteer applicant is under the age of 18 the volunteer and parents/legal guardian(s) must sign)

Date

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

Monday

Tuesday

Wednesday

Thursday

Friday

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.

Contact Information