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FHTRC Test Form
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Step
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Intro
Please describe any disorders, medical conditions or injuries that may impact your ability to manage the physical and/or emotional demands of working in equine assisted activities. Volunteer responsibilities may include communicating with others, following directions, working independently, walking for extended periods of time, jogging short distances, working in hot/humid/cold conditions, working with clients who may have mild to severe mental and/or physical challenges, and working with large animals.
Height(Needed for assignments for the role of side walker)
Do you have any horse Expierence?
Yes - Please Describe
No
Please Describe Your Horse Experience
Do you have any experience wiht individuals with disabilities?
Yes - Please Describe
No
Please describe your experience with individuals with disabilities:
Can You Walk 45 minutes, or jog short distances?
Yes
No
can you hold your arm above your shoulder and support a modest amount of weight?
Yes
No
Disclosure Statement
I,
*
First
Last
affirm that HAVE/HAVE NOT been convicted, or pending conviction, of a crime in any state or country.
*
Have - Please Describe
Have Not
If You Have Been convicted, or pending conviction, of a crime in any state or country please describe...
Affirm Information
*
Affirm
I hereby affirm that the information I provide is true and correct. I further affirm that in the event
that I am arrested for or convicted of an offense that would constitute grounds for denying
participation in a program, activity, or service under the Child Protective Services Law, or am named
as a perpetrator in a founded or indicated report, I must provide written notice to FHTRC no later
than 72 hours after the arrest, conviction, or notification that I have been listed as a perpetrator in
the statewide database. I understand that failure to disclose this information is a misdemeanor and
shall be subject to discipline up to and including termination or denial of volunteer/ employed position.
Disclosure Statement Signature
To sign this form, please enter your name and today's date.
Name
*
First
Last
Today's Date
Background Check
Adults applying for or holding an unpaid position as a volunteer with a child care service, school, program, activity, or service responsible for a child’s welfare or having direct volunteer contact with children will need clearances. All prospective volunteers must obtain the following clearances:
1. Report of criminal history from the Pennsylvania State Police (PSP); and
2. Child Abuse History Clearance from the Department of Human Services (Child Abuse).
Additionally, a fingerprint based federal criminal history (FBI) submitted through the Pennsylvania State Police or its authorized agent is required if the volunteer has lived outside the Commonwealth of Pennsylvania in the last 10 years.
If the volunteer is not required to obtain clearances, they must swear or affirm in writing that they are not disqualified from service based upon a conviction of an offense under §6344.
Clearances can be obtained at:
www.KeepKidsSafe.pa.gov
Background Check Signature
To sign this form, please enter your name and today's date.
Name
*
First
Last
Today's Date
*
Next
Release of Liability For Staff and Volunteers
Inherent Risks
*
Yes - Initial Below
Whereas, I acknowledge the inherent risks involved in riding and working around horses, which risks can include, but are not limited to, bodily injury or even death caused by a fall, a kick or a bite from a horse. I understand that horses by nature are unpredictable and that horseback riding and/or working and being around horses is hazardous by nature and will expose me to above normal risks. I further understand that both horse and rider can suffer injury in normal use or competition and schooling and that I assume the enumerated risks.
Initial
*
Certify Health
*
I am in good heatlh - Initial Below
Whereas, I certify that I am in good health and am physically capable of participating in this activity and have informed Fair Hill Therapeutic Riding Center of any conditions that may pose a safety concern to the horse, the staff, or myself.
Initial
*
Safety
*
I agree - Initial Below
In Consideration, therefore for the privilege of taking lessons and working around horses while engaging in activities provided by Fair Hill Therapeutic Riding Center at Wynsum Equestrian Center, Maplewood Farms, and/or Quiet Hill Stable I agree that I am responsible for my own safety and that for the safety of my minor child, if an, named below.
Safety Initial
*
Acknowledgement of Release - Initial Below
I Acknowledge and Agree
Therefore, I acknowledge and agree in signing this release, that Fair Hill Therapeutic Riding Center and any of its employees, instructors, managers, agents, owners of leased horses and facility, and volunteers, will not be held liable if I the undersigned, or my minor child, suffer personal injury or death, or sustain any damage or loss as a result of my participation in horse related activities at Fair Hill Therapeutic Riding Center, Inc.
Acknowledgement of Release Initial
Parent/Guardian Representation and Acknowledgement
Acknowledge and Agree
In the event this form is signed by the Parent/Guardian of a child, then all representations and acknowledgements herein are expressly made, by, for and on behalf of the parent/guardian and child.
Parent/Guardian Rep and Acknowledgement Initial
Release of Liability For Staff and Volunteers Signature
To sign this form, please enter your name, todays date, address, phone, alternate phone number and email. Name of minor and date if applicable.
SIGNATURE OR (Parent or guardian if under 18)
*
First
Last
Today's Date
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Alt. Phone
Email
*
Minors Name
First
Last
Today's Date
Next
Emergency Contacts Authorization for Emergency Medical Treatment
In the event emergency medical aid or treatment is required due to illness or injury during the process of receiving services or aiding in providing services at Fair Hill Therapeutic Riding Center, I authorize FHTRC to:
Checkboxes
Secure and retain medical treatment and transportation if needed.
Release medical records upon request to the authorized individual or agency involved in the medical emergency treatment
Emergency Contact
Name
*
First
Last
Phone
Physician
Name
*
First
Last
Phone
Preferred Medical Facility
Health Insurance Company
Policy#
Medical Treatment Consent
Choose Consent Plan
Consent Plan: This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “lifesaving” by the physician. This provision will only be invoked if the person listed above is unable to be reached.
Non-Consent Plan: I do not give my consent for emergency medical treatment or aid in the case of illness or injury during the process of receiving or aiding in providing services at FHTRC.
Consent Plan Signature
To sign this form, please enter your name and today's date.
Date
SIGNATURE OR (Parent or guardian if under 18)
*
First
Last
Non-Consent Plan Signature
To sign this form, please enter your name and today's date.
Date
SIGNATURE OR (Parent or guardian if under 18)
*
First
Last
Parent or Guardian Name
*
First
Last
Name of Minor
*
First
Last
Next
Photo/Video/Volunteer Information Policy and Release
FHTRC may choose to use photos, videos and rider information (history, diagnoses etc.) for a variety of reasons including but not limited to the following:
● Marketing
o Brochures
o Posters
o Social media
o Video demonstrations
● Educational purposes
o Group presentations for funding
o Public outreach
o Skills training for therapeutic riding
It is always our intention to respect the privacy of our riders and their families. We will not knowingly or intentionally use the information described above without your express consent.
Please indicate below your permission for use of your/your rider’s information for marketing and educational purposes as outlined above.
Photo Video Permission
I AGREE TO GRANT FHTRC PERMISSION TO USE PHOTOS, VIDEOS AND BASIC INFORMATION FOR PURPOSES OF MARKETING AND EDUCATIONAL PURPOSES.
I DO NOT AGREE TO GRANT FHTRC PERMISSION TO USE PHOTOS, VIDEOS AND BASIC INFORMATION FOR PURPOSES OF MARKETING AND EDUCATIONAL PURPOSES.
Volunteer's Name
*
First
Last
Date
Photo/Video/Volunteer Information Policy and Release Signature
To sign this form, please enter your name and today's date.
SIGNATURE OF VOLUNTEER OR (Parent or guardian if under 18)
*
First
Last
Date
Next
FHTRC Confidentiality Policy
Volunteers under the age of 18 must have their parent/ legal guardian sign this page and ensure their child understands and adheres to this policy.
Confidentiality Policy: Participants and their families have a right to privacy that gives them control over the dissemination of their medical or other sensitive information.
I. FHTRC shall preserve the right of confidentiality of all individuals in its programs, including volunteers and staff.
II. The volunteers and staff of FHTRC shall keep confidential all medical, social, referral, personal and financial information regarding a person and his/her family.
III. The volunteers and staff of FHTRC shall keep confidential names/ diagnoses of participants as well as any incidents involving participants, volunteers, staff, or horses.
IV. Anyone who works, volunteers, or provides services for FHTRC shall be bound by this policy. This includes but is not limited to: • Staff and employees • Independent contractors • Volunteers • Board Members/ Advisory Council
V. As a general rule, children under the age of 18 do not have the legal authority to consent to disclosure of medical or other sensitive information. Only parents, legal representatives, or others defined by state stature generally have this authority.
VI. Please report any sensitive information and/or breach of confidentiality to one of FHTRS’s PATH Certified Instructors or to the Executive Director, who will then follow FHTRC protocol.
VII. Penalties that can result from breaching confidentiality may include reprimand, loss of certain job responsibilities, and termination.
Statement of Confidentiality
I Understand
Statement of Confidentiality
I have read and will observe the above Confidentiality Policy of FHTRC. I understand
that all information (written and verbal) about participants at FHTRC is confidential and will not be shared with anyone without the expressed written consent of the participant and their parent/legal guardian or authorized caregiver, in the case of minor.
FHTRC Confidentiality Policy Signature
To sign this form, please enter your name and today's date.
Name
*
First
Last
Date
Submit
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