Volunteer Application

Employment Information
Military Status

Active DutyReserveVeteranDisabled VeteranNot Applicable
Occupation / Professional Experience
My employer gives time off for volunteering:

YesNo
My employer matches cash donations:

YesNo

Background Check

I understand that a criminal background check may be performed for all volunteers aged 18 and over and that the following information will be verified. I give permission to make inquiry of others concerning my suitability to act as a volunteer at New Hope Equine Assisted Therapy.
Background Consent Typed Signature*
First and Last Name
Date - Background Check Consent*

MonthDayYear
Date
Driver's License
State
Driver's License
Have you ever been convicted of a criminal offense?*

YesNo
If yes, when?
Please explain:

For applicants under the age of 18, parental/guardian signatures will be required in addition to yours on the following pages.

If your parent/guardian is available to complete the online form with you now, then please continue, if not, you can choose from the options below:

1. You can save this form and complete it later. Click on the save icon at the bottom of the screen. (On mobile devices - click on the page numbers to find the save option.) You can save the link and come back when you are ready. You can also request an automated email to be sent with the link.

- OR -

2. You can complete the form online, skipping the parent/guardian signatures. But first, download this PDF for your parent/guardian to sign. If you use the PDF form, you will need to mail, email or bring it to New Hope before your application will be accepted and processed.
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone
Should we use the Parent/Guardian phone when contacting the volunteer?

YesNo, use the Volunteer's phone as provided earlier
Parent/Guardian Email
example@example.com
Should we use the Parent/Guardian email when contacting the volunteer?

YesNo, use the Volunteer's email as provided earlier

Liability Release

I acknowledge the risks and potential for risks of horseback riding and working with horses, 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 New Hope Equine Assisted Therapy, Inc., its Board of Trustees, Instructors, Therapists, Aides, Volunteers, and/or Employees for any and all injuries and/or losses I may sustain while participating as a New Hope 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 & 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.

Please type your first and last name below, confirm the date and check the Electronic Signature box to acknowledge you have read and understand the liability release.
Liability Release Typed Signature*
First and Last Name
Date - Liability Release *

MonthDayYear
Parent/Guardian Liability Release Typed Signature*
First and Last Name
Date - Parent/Guardian Liability Release *

MonthDayYear

Confidentiality Policy

At New Hope, we place great importance on protecting the confidential information of our clients, our staff and our volunteers. “Confidential Information” includes, but is not limited to, personally identifiable information such as surnames, telephone numbers, addresses, e-mails, etc., as well as the non-public business records of New Hope. 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 New Hope staff. Volunteers must seek staff permission before taking any pictures or videos.

Please type your first and last name below, confirm the date and check the Electronic Signature box to acknowledge you have read and understand the New Hope Confidentiality Policy and agree to abide by same.
Confidentiality Policy Typed Signature*
First and Last Name
Date - Confidentiality Policy *

MonthDayYear
Date
Parent/Guardian Confidentiality Policy Typed Signature*
First and Last Name
Date - Parent/Guardian Confidentiality Policy*

MonthDayYear
Date

Photo/Media Release

Choose below to consent or not to the following: 1) New Hope Equine Assisted Therapy, Inc. may use my photograph or image in its print, online and video publications; 2) Release New Hope Equine Assisted Therapy, 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, DVDs, website images or written materials, incorporating photos/images of me.

Make your selection from the options below then please type your first and last name, confirm the date and check the Electronic Signature box to acknowledge you have read and understand the options for the Photo/Media release.
Photo/Media Release*
Select one response and sign in the next block
Photo/Media Release Typed Signature*
Date - Photo/Media Release*

MonthDayYear
Date
Photo/Media Release Parent/Guardian Typed Signature*
First and Last Name
Date - Parent/Guardian Photo/Media Release*

MonthDayYear
Date

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 the agency, I authorize New Hope 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.
In case of Emergency, contact*
First and Last Name
Emergency Contact Phone*
Physician’s Name*
Physician's Phone*
Name of Practice*
Preferred Medical Facility*
Health Insurance Carrier*
Health Insurance Policy #*
Please indicate any allergies*
In the next box, please indicate any disability, limitations, medications or medical conditions that may affect your volunteer role, with or without reasonable accommodations, of which we should be aware. To meet safety standards, there are specific physical requirements that must be met for roles working with horses and riders. We will work with anyone with any disability to find the right role for you
Special Conditions*
CONSENT PLAN (to be invoked in the event that your Emergency Contact cannot be reached I give consent for emergency medical treatment/aid (including x-ray, surgery, hospitalization, medication, and any treatment procedure deemed “life saving” by the physician) in the event of illness or injury while on the property of the agency.*
Emergency Medical Treatment*

ConsentNon-Consent
* If you choose non-consent for emergency medical treatment/aid in the event of illness or injury while on the property of the agency, please request a Non-Consent Form, which requires notarization.
Please type your first and last name below, confirm the date and check the Electronic Signature box to acknowledge you have read and understand the liability release. For volunteers under 18 years of age, both parent & volunteer signatures are required.
Emergency Medical Consent Plan Typed Signature*
First and Last Name
Emergency Treatment Plan Consent Signature Date*

MonthDayYear
Date
Parent/Guardian Emergency Consent Typed Signature (required for minors)
Type First and Last Name
Parent/Guardian Emergency Consent Typed Signature (required for minors)

MonthDayYear
Date

Thank you for your interest. Upon submission, this form will be sent to the Volunteer Coordinator at New Hope Equine Assisted Therapy. No further action is required. You should receive a call or email from the Volunteer Coordinator within a few business days.
Sales Force Full Name - auto populated

First NameLast Name
Salesforce email
example@example.com
Sales Force Phone Number
Please enter a valid phone number.
Should be Empty:

Liability Release

Confidentiality Policy