Welcome to Triple H Equitherapy, Inc. d/b/a “Hannah’s Horseshoes of Hope”, a non-profit therapeutic horseback riding program for challenged people of all ages. So that we can best utilize your experiences and interests, please complete this application as fully as possible. Please fill out BOTH sides.
I. PERSONAL Date: _______________________________
Name: ______________________________________________________________ Birth Date: __________________________
Address: ____________________________________________________________ Drivers License: ______________________
City: ____________________________________________ County: _______________________ Zip: _________________
Social Security No.: ________________________ Home Phone: _____________________ Work Phone: ____________________
Occupation: ______________________________________ Email Address: ______________________________________________
Employer : _________________________________ Affiliation (school, group, organization): _______________________________
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II. INTERESTS
Why do you wish to volunteer in this program? _____________________________________________________________________
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Do you have special talents that you could offer us (artistic, sign language, computer, photography, carpentry, etc.)? ______________
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Your general background (schooling, work experience, etc.) __________________________________________________________
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How did you find out about Hannah’s Horseshoes of Hope? (Check all that apply) ____ Radio ____ TV ____ Newspaper
____ School
Group/organization (please specify) ______________________________________________________________________________
Friend(s) – Please Name _______________________________________________________________________________________
Other (please specify) _________________________________________________________________________________________
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III. SPECIAL EXPERIENCE
Have you had any experience working with persons who are visually or hearing impaired, or who are physically or emotionally disabled? ___________________________________________________________________________________________________
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Please describe, including specific skills and/or degrees: ______________________________________________________________
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Have you had any experience with horses? Please describe:____________________________________________________________
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First Aid or CPR certification? First Aid ___________ CPR ___________ Expires _____________
Would you be interested in periodic educational and idea-sharing meetings? ________ Subjects: ____________________________
_______________________________________________________________________________________________________________________________________________________Time Preferred: ___________________________________________________
IV. SPECIAL OPPORTUNITIES
Would you be interested in helping in any of the following areas?
Tack Cleaning/Repair _________________ Fundraising ____________________
Barn/Ground Maintenance _____________ Telephoning ____________________
Public Relations/Marketing ____________ Mailings _______________________
Special Events Committee _____________ Special Events Planning ___________
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V. REFERENCES
Please list two non-family references (Students must add as a third reference a teacher or counselor):
Name __________________________ Relationship __________ Daytime Phone # _____________Evening Phone # _____________
Name __________________________ Relationship __________ Daytime Phone # _____________Evening Phone # _____________
Name __________________________ Relationship __________ Daytime Phone # _____________Evening Phone # _____________
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VI. STATEMENT OF UNDERSTANDING, AUTHORIZATION, AND RELEASE
I, ____________________________________, (“Volunteer”), am over 18 years of age and fully competent to make this Statement of Understanding, Authorization, Release and Indemnity (“Statement”), which I have read and understand. I understand the information I have provided may be verified and permit Hannah’s Horseshoes of Hope to inquire of others concerning by suitability as a volunteer. In the course of volunteering, I may deal with confidential information and agree to keep said information in my strictest confidence. The relationship between Hannah’s Horseshoes of Hope and me is an “at will” arrangement and may be terminated at any time, without cause, by either Hannah’s Horseshoes of Hope or me. I understand that, as a volunteer, I will assist in riding, instruction of mentally or physically challenged riders and that I will work with and around horses, as well as riders. I understand that I cannot serve as a volunteer until this Statement has been signed.
In return for the opportunity to serve as a volunteer, I hereby forever release, acquit and discharge Hannah’s Horseshoes of Hope and its officers, directors, trustees, agents, employees, representatives, affiliates, successors and assigns (collectively the “Released and Indemnified Parties”) from any and all claims, demands and causes of action of any and every kind or nature, including those caused in whole or it part by the negligence of any of the Release and Indemnified Parties, which I may now or in the future have against any or all of the Released and Indemnified Parties and that arise in whole or in part as a result of my involvement with Hannah’s Horseshoes of Hope. I also understand and agree that Hannah’s Horseshoes of Hope assumes no liability for accidents or act of negligence or gross negligence by anyone, including the Releases and Indemnified Parties.
I further agree to fully indemnify and defend any of the Released and Indemnified Parties against any and all claims, demands or causes of action of any and every kind or nature (including attorney’s fees and other defense costs), including those caused in whole or in part by the negligence of any or all of the Released and Indemnified Parties, which directly or indirectly relate to personal injuries or property damages sustained by me and that arise in whole or in part as a result of my involvement with Hannah’s Horseshoes of Hope. If any provision of the Statement is determined to be unenforceable, all other provisions shall remain in full force and effect.
SIGNED: _________________________________________________________________ Date: _______________________
Volunteer
I represent to Hannah’s Horseshoes of Hope that I am the parent or guardian of the Volunteer whose signature appears above. On behalf of that Volunteer, I agree and accept all of the provisions of the foregoing Statement of Understanding, Authorization, Release Indemnity. I am authorized to sign this Statement of behalf of the Volunteer and my doing so legally binds the Volunteer as if he/she were not a minor.
SIGNED: _________________________________________________________________ Date: _______________________
Volunteer’s Parent or Guardian (Necessary if Volunteer is under 18 years of age)