Volunteer Information Form (This form MUST be filled out in
it's entirty)
Name:__________________________________________________________________________________________
Address: _______________________City:____________State:____Zip:_______
Phone:
Home:______________Work:______________Cell:_____________
Date of birth:____________E-Mail:____________________________________
Employer________________________________________________________
IN CASE
OF EMERGENCY CONTACT:
Please contact:
Name:_________________________________Relationship:______________________
Address: ____________________City:___________ State:_______Zip:_______
Phone: Home:_______________________Work:__________________________Cell:______________________
Physician:________________________________________________Phone:________________________________
Hospital:________________________________________________________________________________________
___ I give my
permision for Flint Hills TRC to secure medical transportation and treatment, including x-ray,surgery, hospitalization and
medicacation.
___ I do not give my consent for emergency
medical treatment. In the event that emergency treatment or aid is required, I request the following procedures to take
place ____________________________________________________________
_________________________________________________________________________________________________
Date:_________
Signature:___________________________________
Date:_________
Signature:___________________________________
Parent or guardian for volunteers under 18 years old
Volunteer Liability Release (MANDATORY)
Under
Kansas law, there is no liability for an injury to or the death of a participant in domestic animal activities resuling from
the inherent risks of domestic animal activities, pursuant to K.S.A. 60-4001 through 60-4004. You are assuming the risk of
participation in this domestic animal activity.
Date:_________ Signature:___________________________________
Date:_________ Signature:___________________________________
Parent or guardian for volunteers under 18 years old
Photo Release
___ I Do ___ I Do Not Consent to and authorize the use and reproduction
by Flint Hills TRC of any and all photographs and any other audio-visual materials taken of me for promotional material, educational
avtivities, exhibitions or for any other use for the benifit of the program.
Date:_________
Signature:___________________________________
Date:_________
Signature:___________________________________
Parent or guardian for volunteers under 18 years old
Areas
You Wish To Volunteer
___ Lead a horse
___ Side Walk
with a client
___ Fundraising/Special Events
___ Barn Maintenance
___ Other ___________________________
How
did you hear about Flint Hill TRC. ___________________________________
_________________________________________________________________
Can
you walk for 30 minutes and jog for short distances? _____________________
Do you have any medical conditions we
need to know about? _________________
Do you have any experience working with horses or the disabled? ____
If
yes, please list your experience. ______________________________________
________________________________________________________________
Please
indicate the days/times you would like to volunteer.
| | Monday | Tuesday | Wednesday | Thursday |
| Morning | | | | |
| Afternoon | | | | |
| Evening | | | | |
