1301 Convent Road, Cullman, AL  35055

Phone:  256-841-6290   Email:  HOPE@hopehorses.org

Volunteer/Staff Application

Volunteer Approval Process:

√ Fully Completed Application

√ Handbook read and Acknowledgement signed

√ Orientation videos viewed

√ Background Check results received, if applicable

√ Application approved by Hope Horses, Inc. staff

√ Name badge issued

Name (Last, First): _____________________________________________________

Date of Birth: _____________________________________________

Address: _____________________________________________________________

City: _____________________________ Zip Code ________________________

E-mail Address: _______________________________________________

Home Phone: ________________ Work: _________________ Cell: _______________

Parent/Caregiver Name(s), if under age 18 or dependent adult: ___________________________________

Parent/Caregiver Contact Information, if different from above: _______________________________________

Primary Emergency Contact (Name and Phone number): _______________________________________

School/Group Association Name (if applicable):

_______________________________________

Name of person in charge of group (if applicable): _______________________________________

Please indicate the day(s) and time(s) you will be Volunteering: _______________________________________

Health History

Please list any and all allergies or physical conditions that may affect you during the time at which you are volunteering: (Easily fatigued, asthma or other breathing issues, allergic to bee stings, knee, hip or back pain or weakness, any major surgeries or conditions that EMS would need to be notified of in the event of an emergency) _____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Authorization for Emergency Medical Treatment

In the event emergency medical aid/treatment is required due to illness or injury to me or my child while being on the property of the agency, I authorize Hope to secure and retain medical treatment and transportation if needed and to release client records upon request to the authorized individual or agency involved in the medical emergency treatment.

Consent:                Yes 􀂉                                No 􀂉

Health Insurance Company _______________________________________________________________

Signature: ___________________________________________Date: _____________

Confidentiality Agreement

I understand that all information (written and verbal) about participants at Hope is confidential and will not be shared with anyone without the expressed written consent of the participant and their parent/guardian in the case of a minor. This includes all medical, social, referral, personal, financial, and otherwise sensitive information. I understand that individuals who breach confidentiality will be removed from the Hope program.

Signature ___________________________________________Date: ______________

Photography Consent

I understand that Hope often takes still pictures and/or videos of students, clients, volunteers and instructors for a variety of reasons. I authorize Hope to take still and/or video photographs of myself, or the individual for which I am legally responsible.

Consent:

Yes􀂉                            No 􀂉

Signature: _________________________________________ Date: _______________

HORSE EXPERIENCE:

Are you comfortable around horses?  No 􀀀 Yes 􀀀 Somewhat. 􀀀 I’m not sure 􀂉

Do you or have you owned horses?  No 􀀀 Yes 􀂉

     For how long? __________________________________

Have you ever worked with horses?  No 􀀀 Yes 􀂉

     In what capacity? ____________________________________________________

Have you had formal lessons or training in working with horses?  No 􀀀 Yes 􀂉

If yes, please list the type and amount of training/riding experience you have had: ______________________________________________________________________

OTHER:

Are you comfortable around people with disabilities?  No 􀀀 Yes 􀀀 I’m not sure 􀂉

Have you ever worked with people with disabilities?  No 􀀀 Yes 􀂉

     In what capacity? ____________________________________________________

Please describe any special skills, training, or talents that you feel might be helpful to us.

_____________________________________________________________________

Please tell us why you would like to volunteer at Hope.

_____________________________________________________________________

How did you hear about Hope? _____________________________________________________________________

Please check which area(s) you are interested in:

___ Barn                                        

___ Lesson                                        

___ Administrative

___ Facility                                                

___ Special Events

___ Fundraising

___ Handyman, grounds maintenance

Knowledge or training you would be willing to offer to benefit the Hope program (i.e. computer skills, carpentry, webmaster, social media management, photography, etc.) ______________________________________________________________________

Background Information:

Have you ever been charged with or convicted of a crime?        Yes 􀂉        No 􀂉

If yes, please explain ____________________________________________________

I, (print name) __________________________ consent to authorize Hope to receive all information from any law enforcement agency, including police departments and sheriff’s departments, of any state or federal government, to the extent permitted by state and federal law, pertaining to any convictions I may have had, including but not limited to crimes committed upon children or animals. I understand that such access is for the purpose of considering my application as a volunteer, and that I expressly DO NOT authorize Hope, its directors, officers, employees, or other volunteers to disseminate this information in any way to any individual, group, agency, organization, or corporation.

Volunteer Signature

Parent/Guardian/Caregiver (if under 18 years of age)

_______________________________________________________________

References:

Please list 3 persons, other than relatives whom we may contact regarding your character.

1 .Name ________________________                Phone Number _________________

2. Name ________________________                   Phone Number _________________

3. Name ________________________                Phone Number __________________

Release of Liability

To be completed by the volunteer or volunteer’s parent, or volunteer’s legal representative if under 18 years of age.

This release of liability is made and entered into on this date _________ , by and between Hope Horses, Inc. hereinafter known as Hope, and staff/participant/volunteer (print name) ______________________, hereinafter known as participant, and (if a minor or incompetent adult) participant’s parent, legal guardian, or legal representative (print name) ____________________________. In return for participation in Hope’s therapeutic horseback riding activities, special events and fundraisers, the participant, his/her heirs, assigns, and legal representatives hereby expressly agree to the following:

  1. Participant agrees to assume any and all risks involved in or arising from participant’s participation or presence upon the property and facilities, including, without limitation, but not limited to the risks of death, bodily injury, property damage, falls, kicks, bites, collisions with vehicles, horses, or stationary objects, fire or explosion, the unavailability of emergency medical care, or the negligence or deliberate act of another person.

  1. Participant agrees to hold Hope and all of its successors, assigns, subsidiaries, franchisee, affiliates, officers, directors, employees, agents, and boarders completely harmless and not liable and release them from all liability whatsoever and agrees not to sue them on account of or in connection with any claims, causes of action, injuries, damages, costs or expenses arising out of participant’s participation and/or presence upon Hope’s property and facilities, including without limitation, those based on death, bodily injury, property damage, including consequential damages, except if the damages are caused by the direct willful and wanton negligence of Hope.

  1. Participant agrees to waive the protection afforded by any statue or law in any jurisdiction whose purpose, substance and/or effect is to provide that a general release shall not extend to claims, material, or otherwise, which the person giving the release does not know or suspect to exist at the time of executing the release.

  1. Participant agrees to indemnify and defend Hope against, and hold it harmless from, any and all claims, causes of action, damages, judgments, costs, or expenses, including attorney’s fees, which in any way arise from participant’s participation and/or presence upon Hope’s property or facilities.

  1. This contract is non-assignable and non-transferable and is made and entered into the State of Alabama and shall be enforced and interpreted under the laws of this state. Should there be any clause in conflict with State Law, then that clause is null and void. When Hope and participant or participant’s parent, legal guardian, or adult caregiver signs this contract, it will then be binding on both parties, subject to the above terms and conditions.

WARNING:  Under Alabama law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities, pursuant to the Equine Activities Liability Protection Act.

Participant (Parent/ Legal Guardian/Legal Representative if under 18 years of age)

Signature ________________________________________________ Date _______________________

HOPE Representative

Signature________________________________________________ Date _______________________

HOPE Office Use Only

Signatures required: (√ when verified)

NOTE: Volunteers under 18 must have co-signed by parent/guardian

Authorization for Emergency Medical Treatment (if applicable) ____ Comment _____________________

Confidentiality Agreement               ____

Photography Consent                      ____

Background Information Consent    ____

Release of Liability                          ____

Handbook Acknowledgement          ____              

Hope Representative Signature     ____

Orientation

Background Check received and acceptable, if applicable ____  N/A ____

Training videos viewed – PATH and Horse Handling _____

Barn Tour including Fire Extinguishers and Emergency Plan _____

Entered into EquiForce _____

Name Tag Made _____

Volunteer/Staff Application Page  of Revised 2-3-16