Volunteer Health History & Photo Release

Volunteer Information Form and Health History

General Information:

Name:____________________________________________ Email:___________________________________

Date of Birth:____________ Home Phone__________________ Cell Phone:_____________________________

Address:___________________________________________ City:_______________ State:_____ Zip:

Employer/School: ___________________________________

Work Address:______________________________________City:________________State:_____Zip:
Work Phone:_________________________________________

Parent/Guardian Name and address (if applicable) __________________________________________________

How did you learn about the program? ___________________________________________________________

Date of last Tetanus vaccination.: ____________________________________

Consult your physician or local health department if you are not up to date with your Tetanus vaccination. It is highly recommended that individuals working in agricultural environments stay current with this vaccination.

Health History

Please describe your current health status, particularly regarding the physical/emotional demands of working in a therapeutic riding program. Address fitness, cardiac, respiratory, bone or joint function, recent hospitalizations/surgeries, or lifestyle changes.

Allergies: __________________________________________________________________________________

Medications: _________________________________________________________________________________

I understand that 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: ___________
Parent / Legal Guardian if Volunteer is under 18
Print name__________________________________________________________________

Volunteer or Staff
Signature: ____________________________________________________ Date:______________________________

Please check which areas you are most interested in:
____Program ____Volunteer____Competitions ____Administration

____Leading a horse
____Horse Shows
____ Office Work
____Sidewalking with a student
____Fund Raising
____Stable Management
____Newsletter or E-news
____Facility Repairs
____Volunteer Recruitment
____Marketing/Public Relations

Photo Release
I ___DO ___DO NOT
Consent to and authorize the use and reproduction by Prospect Riding Center of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.

Signature:__________________________________________________________________________ Date:_____________
Parent / Legal Guardian if Volunteer is under 18

Background Information:
Have you ever been charged with or convicted of a crime? Y N. Please explain

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

Signature____________________________________________________________________________ Date:____________
Print name___________________________________________________________________________
Parent / Legal Guardian if Volunteer is under 18
Current Driver’s License: Y N License Number________________________________State:_______

Volunteer Information Form and Health History
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