Front Range Exceptional Equestrians
PO Box 272452
Fort Collins, CO 80527
Voice Mail (970) 221-
VOLUNTEER FORM AND RELEASE
Today’s Date____________________ Name_______________________________________________________
Mailing Address______________________________________________________________________________
Street/ Box
City______________________________________________________Zip_______________________________
Phone (H)____________________ (W) _____________________ (C)___________________________________
Email Address _______________________________________________________________________________
Date of Birth_________________________ Occupation_______________________________________________
Parent/ Legal Guardian Name/ Address if volunteer is under 18__________________________________________
____________________________________________________________________________________________
How did you learn about our program? _____________________________________________________________
Have you ever volunteered in a therapeutic riding program before? Please explain __________________________
____________________________________________________________________________________________
Have you ever been convicted of a felony or any crime against children or animals? Please explain any Yes answer______________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Do you have any physical limitations which might affect your ability to assist a disabled client during a 60 minute riding lesson? _____________________________________________________________________________________
____________________________________________________________________________________________
Do you have any experience working with disabled individuals? _________________________________________
____________________________________________________________________________________________
Do you have any experience transferring a disabled person from a wheelchair or walker? If yes, would you be willing to be trained
to help with mounting riders on horses? ______________________________________________________
____________________________________________________________________________________________
Do you have experience working with horses/ponies? Please explain ____________________________________
____________________________________________________________________________________________
If you are 12-
Would you be comfortable walking for an hour in sand or dirt? ___Yes ___ No
Can you jog for short distances? ___ Yes ___ No
Can you hold your arm above shoulder height and support a modest weight for 30 minutes or more? ___Yes ___No
Do you have any allergies/ asthma that may affect your work in the barn? Please explain Yes answers ________________________________________________________________________________________________
________________________________________________________________________________________________
To help us use your time most efficiently, please indicate the days and times you would be available for volunteer activities for our program: Circle day(s)/time(s) available
Monday Tuesday Wednesday Thursday Friday Saturday
Mornings Afternoons Evenings
Check areas you are interested in, (you may choose more than one):
Program Special Events Administration
__Horse Handling __Horse Show __Photo/Video Recording
__Sidewalking with a student __Fundraising Events __Board of Directors
__Tack/ Equipment cleaning __Trail-
__Volunteer recruitment __Special Olympics __E-
__Grant Writing
__Public Relations
The Job I most prefer to have is :
__Weekly class volunteer assisting the disabled riders
__Work on Projects/ Committees (I have checked areas of interest above)
__I have volunteered for at least one 6-
How much notice do you need to get to classes to sub? 30 minutes or less _____ 1 hour or more _____
At which location can you sub? ___Legacy ___CSU ___Either
I understand the information provided above is accurate to the best of my knowledge. I know of no reason why I should not participate in this center’s program.
Signature___________________________________________Date___________________
Photo Release
I DO/ DO NOT (circle one) consent to and authorize the use and reproduction by Front Range Exceptional Equestrians of any and all photographs and other audiovisual material taken of me/my child/ my ward for promotional printed material, educational activities, exhibitions, or for any other use for the benefit of the Front Range Exceptional Equestrians program.
__________________________________________________ Date ___________________
Volunteer, Parent or Legal Guardian
Volunteers MUST Complete and sign these releases. If under 18 a Parent or Guardian must sign.
Confidentiality Policy
Volunteers, Clients and their families have a right to privacy that gives them control
over the dissemination of their medical and other sensitive information. Front Range
Exceptional Equestrians will preserve the right of confidentiality for all individuals
in this program. The policy includes keeping confidential all medical, social, referral,
personal and financial information regarding a person and his/her family. Anyone
who works for or volunteers for Front Range Exceptional Equestrians therapeutic riding
program is bound by this policy. This includes but is not limited to: full and
part-
Disclosure of medical or sensitive information to individuals within Front Range Exceptional Equestrians will only occur on a need to know basis, so that appropriate services may be provided to the client. Disclosure of information to outside agencies or individuals will only occur with specific written consent of the client of parent or legal guardian.
Breech of confidentiality whether accidental or intentional will result in penalties ranging from reprimand, loss of job responsibilities, or termination depending on the circumstances of the incident.
By Signing below I state that I understand and will observe the confidentiality policy of Front Range Exceptional Equestrians therapeutic riding program.
Signature of volunteer__________________________________________________Date_______________________
Signature of Parent if under 18___________________________________________ Date ______________________
Liability Release
WARNING: Under Colorado law, an equine professional is not liable for an injury
to or death of a participant in equine activities resulting from the inherent risks
of equine activities, pursuant to Section 13-
________________________________(Name) requests participation as a volunteer in the Front Range Exceptional Equestrians therapeutic riding program. I acknowledge the risks and potential risk of injury during horseback riding therapy and working with horses. However, I feel that the possible benefit to myself/ my child/ my ward warrants assumption of these risks. I hereby, intending to be legally bound, for myself, my heirs, and my assigns, executors and administrators, waive and release forever all claims for damages against Front Range Exceptional Equestrians, its Board of Directors, Instructors, Therapists, Aides, Volunteers, Horse Owners, Property Owners, and/ or Employees for any and all injuries and /or losses that I/ my child/ my ward may sustain while participating in Front Range Exceptional Equestrians therapeutic riding program.
_______________________________________________________________ Date_____________________________
Signature of person releasing liability
______________________________________________________________ ___________________________________
Printed Name Relationship to Volunteer
Emergency Treatment Release
Name_______________________________ Parent/Guardian (if minor)_________________________________________
Address___________________________________________________________________________________________
Phone Day________________ Evening___________________ Cell___________________________________________
Whom should we contact in case of emergency during your time at Front Range Exceptional Equestrians?:
Name___________________________________________________________ Phone____________________________
Preferred Doctor or hospital___________________________________________________________________________
Please list any health or medical condition which may affect your safety and that emergency personnel should be aware of ( allergy to bees or insects or medication, asthma, diabetes, seizures, hearing impairment, limited mobility, balance difficulty, visual impairment, etc.)
Consent for Emergency Treatment
I give my consent for emergency medical treatment/aid in the case of illness or injury
during my/ my child’s participation in the Front Range Exceptional Equestrians program
or while being on the property of the agency. This authorization includes x-
Consent Signature ____________________________________________________________ Date_________________
-
NON-
I DO NOT give my consent for emergency medical treatment in the case of illness or injury while participating in the Front Range Exceptional Equestrians program or while being on the property of the agency. If emergency treatment/ aid is required, the following should occur:
__________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________
For CHILDREN UNDER THE AGE OF 18, A PARENT WILL REMAIN ON SITE DURING ALL ACTIVITIES.
NON-
Staff Signature __________________________________________________________________ Date________________