Volunteer Registration Form Note: If you have difficulty with the date fields, try entering the dates in YYYY-MM-DD format. Name (required) Date of Birth Age Address (Street) Address (City) Address (State) Address (Zip) Phone (Home) Phone (Work) Phone (Cell) Email (required) Preferred method of contact: Home PhoneWork PhoneCell PhoneEmail Parent / Guardian Name (for volunteers under 18) Parent / Guardian Phone (for volunteers under 18) Volunteer Interests (check all that apply) Please Note: Previous horse experience is required to be a lead walker during lessons. barn chores including, but not limited to stall mucking, watering, hayingside walker during lessonslead walker during lessons (previous horse experience required)other (please describe below) If you selected other above, please describe your other interests What are your reasons for wanting to volunteer at Victoria Acres? personal fulfillmentschool requirementcommunity service Availability What days are you available? MondayTuesdayWednesdayThursdayFridaySaturdaySunday Number of hours / week (approximately) Times available Confidentiality Policy At Victoria Acres Equine Facility, Inc., we place great importance on protecting the confidential information of our staff, volunteers, and especially our clients. “Confidential information" includes, but is not limited to, personally identifiable information such as surnames, telephone number, addresses, emails, etc., as well as the non - public records of Victoria Acres. In particular, medical information about clients, and information about their disabilities or special needs, must be protected as confidential information. Volunteers shall never disclose confidential Information to anyone other than Victoria Acres staff. Volunteers must seek staff permission before taking any pictures or videos. I have read and understand the Victoria Acres Equine Facility, Inc.'s Confidentiality Policy and agree to abide by same. Volunteer's Signature Date Parent or Guardian's Signature (if volunteer under 18) Date Liability Release I acknowledge the risks and potential for risks of horseback riding and related equine activities including grievous bodily harm. However, I feel that the possible benefits to myself are greater than the risks assumed. I hereby, intending to be legally bound for myself, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against Victoria Acres Equine Facility, Inc., its Board of Directors, instructors, therapists, aides, volunteers, and / or employees for any and all injuries and / or losses I may sustain while participating as a Victoria Acres volunteer from whatever cause including, but not limited to, the negligence of these related parties. The undersigned acknowledges that he / she has read this Volunteer Registration and Release form in its entirety ; that he / she understands the terms of this release and has signed this release voluntarily and with full knowledge of the effects thereof. Volunteer's Signature Date Parent or Guardian's Signature (if volunteer under 18) Date Photo and Publicity Release Please read each of the following items before choosing a selection below. 1) Victoria Acres Equine Facility, Inc. to use my (my child's) photograph or image in its print, online and video publications ; 2) Release Victoria Acres Equine Facility, Inc., its employees and any outside third parties from all liabilities or claims that I might assert in connection with the above described activities ; and 3) I waive any right to inspect, approve or receive compensation for any materials or communications, including photographs, videotapes, DVD's, website images or written materials incorporating photos / images of me (my child) I hereby consent to and authorize the aboveI DO NOT consent to, nor do I authorize the above Authorization for Emergency Medical Treatment for Volunteers In the event emergency medical aid / treatment is required due to illness or injury while being on the property of Victoria Acres, I authorize Victoria Acres to: 1) Secure and retain medical treatment and transportation, if needed. 2) Release records upon request to the authorized individual or agency involved in the medical emergency treatment. Emergency Contact Name Emergency Contact Phone Preferred Medical Facility Please indicate any allergies Please indicate any disability, limitations or medical conditions that may affect your volunteer role, with or without reasonable accommodations, which we should be aware of Consent Plan (to be invoked in the event that your emergency contact cannot be reached) I give consent for emergency medical treatment / aide (including X - ray, surgery, hospitalization, medication and any treatment procedure deemed "life saving" by a physician in the event of illness or injury while on the property of Victoria Acres. Volunteer's Signature Date Parent or Guardian's Signature (if volunteer under 18) Date Please complete all required fields and check the boxes next to the release(s) before sending.