New Volunteer Application

Biographical
Name:*
First Middle Last Suffix
Date of Birth:*
minimum age: 14
Date Format: MM slash DD slash YYYY
Height:*
Example: 5' 11"
Phone:*
Phone Type:*
Email:*
Email Type:*
Home Address:*
Street Address Address Line 2 City State ZIP Code
Name of Parent / Guardian:
if volunteer is under the age of 18
First Middle Last Suffix
Parent / Guardian Phone:
Parent / Guardian Phone Type:
Parent / Guardian Email:
Parent / Guardian Email Type:

Employment & Education
Employment Status:*
- Full-Time
- Part-Time
- Self-Employed
- Unemployed
- Retired
- Student
Occupation:*
if none, enter n/a
Current / Retired Employer:*
if none, enter n/a
Current / Retired Employer Address:
Street Address Address Line 2 City State ZIP Code
School:*
Area(s) of Study / Degree:*
School Address:
Street Address Address Line 2 City State ZIP Code

Volunteer Experience
Please list any programs / agencies for whom you have volunteered in the past five years:*
Example: CTRH - 04/2000 to 12/2003 - administrative support (if none, enter n/a)

References
Please list TWO or more people, who are not related to you, who can provide a personal / professional reference:*
Example: John Smith - (513) 111-1111

Photo Release
I DO / I DO NOT consent to and authorize the use and reproduction by Cincinnati Therapeutic Riding and Horsemanship of any and all photographs and any other audio-visual materials taken of me for promotional material, educational activities, exhibits, electronic publications (including websites) or for any other use for the benefit of the program.
Consent:*
- I DO consent to photo release
- I DO NOT consent to photo release
Electronic Signature:*
type full legal name
Parent/Guardian Electronic Signature:*
type full legal name. required if applicant under the age of 18. if applicant 18 or older, enter n/a.
Signature Date:*
Date Format: MM slash DD slash YYYY

Volunteer Confidentiality Policy
It is the policy of Cincinnati Therapeutic Riding and Horsemanship to respect the privacy of riders/participants, volunteers, and personnel and hold in confidence all information obtained in the course of service. Information considered to be confidential includes all medical, familial, social, referral, personal and financial concerns regarding a participant and/or his/her family; volunteer or personnel. Such information is considered confidential regardless of how it is obtained, whether directly from the participant or family; CTRH staff, volunteer or others associated with CTRH; or inadvertently from other sources, such as but not limited to a chart, computer screen or overheard conversation. Instructors may deem it necessary to inform individuals directly associated with participant/rider medical/behavior information related to providing therapeutic riding services to the participant/rider. This information will be used solely for therapeutic riding purposes. Otherwise, information and confidences will not be disclosed to anyone, except: 1) As mandated by law; 2) To prevent a clear and immediate danger to a person or persons; 3) Where requested in a civil, criminal, or disciplinary action arising from the therapy (in which case rider/participant confidences may only be disclosed in the course of action); 4) If there is a waiver previously obtained in writing and then such information may only be revealed in accordance with the terms of the waiver; and 5) As required for accreditation reviews.
Electronic Signature:*
I have read and understand the CTRH confidentiality policy as described above and agree to observe its principles. I shall respect the privacy of riders/participants, volunteers, and personnel and hold in confidence all information obtained in the course of my service at CTRH. I also recognize that confidentiality and privacy requirements apply to fellow volunteers/staff members. In addition, I understand that photographs of riders/participants are prohibited unless specific permission is given by CTRH management under PATH guidelines. (type full legal name)
Parent/Guardian Electronic Signature:*
type full legal name. required if applicant under the age of 18. if applicant 18 or older, enter n/a.
Signature Date:*
Date Format: MM slash DD slash YYYY

Volunteer Release of Liability
As a volunteer with Cincinnati Therapeutic Riding and Horsemanship, I acknowledge the risks and potential for risks of horseback riding, hippotherapy and horse related activities and programs. However, I feel the possible benefits to myself and the participant(s) I work with are greater than the risk 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, known or unknown whether existing on the date of agreement or in the future, against Cincinnati Therapeutic Riding and Horsemanship, its Board of Directors, employees, instructors, therapists, volunteers equines and equine owners, for any and all injuries and/or losses I may sustain while participating in Cincinnati Therapeutic Riding and Horsemanship. I understand that some of the inherent risks in equine activity include, but are not limited to: A) The propensity of an equine to behave in ways that may result in injury, death, or loss to persons on or around the equine; B) The unpredictability of an equine’s reaction to sounds, sudden movement, unfamiliar objects, persons or other animals; C) Hazards, including, but not limited to, surface and subsurface conditions; D) A collision with another equine, another animal, a person, or an object; E) The potential of an equine activity participant to act in a negligent manner that may contribute to injury, death, or loss to the person of the participant or to other persons, including, but not limited to, failing to maintain control over an equine or failing to act within the ability of the participant.
Electronic Signature:*
I agree that I have been given sufficient time to read, understand and ask questions, if any, concerning the nature and scope of this Release of Liability; and I agree to the Release of Liability as stated above. (type full legal name)
Parent/Guardian Electronic Signature:*
type full legal name. required if applicant under the age of 18. if applicant 18 or older, enter n/a.
Signature Date:*
Date Format: MM slash DD slash YYYY

Volunteer's Authorization for Emergency Medical Treatment
Consent Plan: In the event emergency medical aid/treatment is required, due to illness or injury, during the process of providing or receiving services or while being on the property of Cincinnati Therapeutic Riding and Horsemanship, I authorize Cincinnati Therapeutic Riding and Horsemanship 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; (3) allow for treatment including x-ray, surgery, hospitalization, medication and any treatment procedure deemed "life-saving" by the physician. This provision will only be invoked if the person(s) below are unable to be reached.
Consent:*
- I DO consent to the emergency medical treatment plan as stated above.
- I DO NOT give consent for emergency medical treatment/aid in the case of illness or injury during the process of providing or receiving services or while being on the property of Cincinnati Therapeutic Riding and Horsemanship.
Electronic Signature:*
type full legal name
Parent/Guardian Electronic Signature:*
type full legal name. required if applicant under the age of 18. if applicant 18 or older, enter n/a.
Signature Date:*
Date Format: MM slash DD slash YYYY
Physician's Name:*
if consent not given, enter n/a
Physician's Phone:*
if consent not given, enter (111) 111-1111
Preferred Medical Facility:*
if consent not given, enter n/a
Any known allergies (i.e. bee stings, medication):*
if none, enter n/a
Person(s) to be contacted in the case of emergency:*
Name Relation Phone
Non-Consent Plan:*
I DO NOT give consent for emergency medical treatment/aid in the case of illness or injury during the process of providing or receiving services or while being on the property of Cincinnati Therapeutic Riding and Horsemanship. In the event emergency treatment/aid is required, I wish the following procedure to take place (if consent given, enter n/a):
Non-Consent Electronic Signature:*
type full legal name. if consent given, enter n/a.
Non-Consent Parent/Guardian Electronic Signature:*
type full legal name. if consent given, enter n/a. required if applicant under the age of 18. if applicant 18 or older, enter n/a.
Signature Date:*
if consent given, enter 01/01/2001
Date Format: MM slash DD slash YYYY

COVID-19 Acknowledgement of Risk and Acceptance of Services
As of May 12, 2020: Required for ALL staff, volunteers, contractors, visitors and clients. I am aware of the risks of contracting or spreading Covid-19 while working or volunteering at Cincinnati Therapeutic Riding and Horsemanship (CTRH); attending an event; and/or receiving face-to-face services from CTRH during the time of a pandemic outbreak, and /or Ohio Governor Mike DeWine's declaration of Responsible Restart Ohio. I am aware that face-to-face services and experiences increase my risk of contracting and passing on the Covid-19 Coronavirus or other disease or illness and agree to release, indemnify and hold harmless CTRH and its officers, managers, agents, employees, volunteers, participants and all other individuals I may come in contact with during this interaction and receiving of services, providing services, attending an event or volunteering within this organization, from any and all claims, demands, causes of action or damages resulting or related in any way to such receiving of services, providing services, attending an event or volunteering at or through CTRH. I agree to and will follow all guidelines for personal hygiene, personal safety and public safety as recommended by Governor DeWine, as well as my individual provider or practitioner. This may include, but is not limited to, waiting in my vehicle until I am asked to enter the building/farm; maintaining social distance; washing my hands prior to and following each session or activity; use of hand sanitizer upon request; wiping down surfaces with disinfecting wipes and/or wearing a protective a mask and gloves. I agree to stay home and/or cancel my services should I have personally exhibited or have been in contact with someone who has presented with illness within the previous 24 hours to 2 weeks, including; cough, sneezing, fever, chest congestion or additional signs of potential spread of any virus or bacteria/disease. In addition, I will follow the recommendations of my provider once I have notified them of these risks in regards to my future services or attendance during this pandemic. CTRH will engage in regular cleaning and sanitizing of the facility, horse tack, grooming supplies and office, restrooms, doors, and frequently touched areas in-between clients and on a daily basis as recommended by the CDC for the safety of clients, employees, volunteers and horses.
Electronic Signature*
I am signing under my own free will and agree to follow these and hold harmless all individuals associated with or through my services acquired from CTRH. (enter full legal name)
Parent/Guardian Electronic Signature:*
type full legal name. required if applicant under the age of 18. if applicant 18 or older, enter n/a.
Signature Date:*
Date Format: MM slash DD slash YYYY

Volunteer Responsibilities
Responsibilities Description*
I have reviewed the Volunteer Responsibilities Description online (https://www.ctrhequinetherapy.org/volunteer)
- Yes
- No
Discretion - Electronic Signature:*
ALL VOLUNTEERS: Volunteering at Cincinnati Therapeutic Riding and Horsemanship is at the sole discretion of CTRH. If at any time the CTRH staff determines that volunteering at CTRH is not an appropriate activity for a volunteer, CTRH may remove a volunteer from the Program. CTRH will not tolerate any volunteer who engages in disruptive conduct, exhibits behaviors that are unacceptable or unsafe, and/or is disrespectful to others. I understand my work for Cincinnati Therapeutic Riding and Horsemanship is being provided in a volunteer capacity and I will not receive any compensation or any other benefit in connection with the volunteer position (type full legal name):
Discretion - Parent/Guardian Electronic Signature:*
type full legal name. required if applicant under the age of 18. if applicant 18 or older, enter n/a.
Signature Date:*
Date Format: MM slash DD slash YYYY

New Volunteer Application

Step 1 of 11

Biographical

Employment & Education

Volunteer Experience

Volunteer Questionnaire

References

Photo Release

Volunteer Confidentiality Policy

Volunteer Release of Liability

Volunteer's Authorization for Emergency Medical Treatment

COVID-19 Acknowledgement of Risk and Acceptance of Services

Volunteer Responsibilities

Name	Relation	Phone