Volunteer Health History & Photo Release

Volunteer’s Name: ______________________________________________________
DOB: ___ / ___ /___ Age: _____ Height: _____ Weight: _____ Male / Female
Ethnicity______________
Address: _________________________________________________ County ________

Home Phone: _____________________ Cell phone: __________________
Preferred phone: ________________________________________________

Email Address: ____________________________________________________________

Employer/School: __________________________________________________________
Address: ___________________________________________ Phone: ________________

Parent/Legal Guardian: ____________________________ Phone: _________________
Address (if different from above): ________________________________________________________________

Referral Source

How did you hear about the program? Client Service Provider ____ Website _____
Facebook ___ Event On Site _____ Event Off Site _____ Friend _____ Media _______
Volunteer ______ Member of Civic Group ___________ FFA _________ 4H __________

Are you completing required volunteer hours? _______ Yes ________ No

What medications are you currently taking, including over-the-counter medications? _______________________________________________________________________
List Allergies __________________________________________________________

Describe your abilities/difficulties in the following areas (include assistance required or equipment needed):

Experience with horses ________________________________________________
________________________________________________________________________
Experience with special needs _________________________________________
________________________________________________________________________
Goals (i.e. Why are you applying for participation?
________________________________________________________________________
________________________________________________________________________

Photo Release

I _____ Do I _____ 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/Participant if over 18