Please let us know what times you are available to volunteer by checking the appropriate boxes below and/or indicating specific hours you would like to come to the farm:

                      Mornings           Afternoons          Evenings

How did you learn about Great and Small?

Do you have any special skills you would like to offer (PR work, carpentry, fundraising, legal, photography, graphic design, etc.)?

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

EMERGENCY MEDICAL TREATMENT:

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving or giving services, or while being on the property of Great and Small, I authorize Great and Small to secure and retain medical treatment and transportation if needed.

Name: _______________ Relationship: _____________ Phone: ___________________

Name: _______________ Relationship: _____________ Phone: ___________________

Preferred medical facility: __________________________________________________

Health Insurance Plan Name: ________________________________________________

Policy number: ________________________________

Policy holder name (if different): ____________________________________________

Please explain your current health status, particularly any information that may impact the physical and emotional demands involved in a therapeutic horse back riding program. Please be sure to address fitness, cardiac, respiratory, bone or joint function, recent hospitalizations/surgeries, and/or lifestyle changes, or any other information regarding your current health or health history of which you believe we should be advised (in the space below):

Date of last Tetanus shot: ____________

Date of most recent TB test: __________

Result?     +       -

Allergies: _____________________________________________

Medications: ___________________________________________

*IF ANY INFORMATION REGARDING YOUR HEALTH CHANGES, PLEASE BE SURE TO UPDATE OUR RECORDS.

_________________________________                  ____________________________

Signature of parent or guardian (if minor)                       Name of child (if applicable)

_________________________________                  ________________________ 

Print name of parent or guardian (if minor)                     Date

LIABILITY / PHOTO RELEASE & BACKGROUND INFORMATION

LIABILITY RELEASE:

AS A VOLUNTEER AT GREAT AND SMALL, I ACKNOWLEDGE THE RISKS AND POTENTIAL FOR RISK OF A HORSEBACK RIDING PROGRAM. HOWEVER, I FEEL THAT THE POSSIBLE BENEFITS TO MYSELF AND THE CLIENTS 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 against Great and Small, its board of directors, instructors, therapists, volunteers and employees for any and all injuries and/or losses I may sustain while participating in the program.

_________________________________                  ____________________________

Signature of parent or guardian (if minor)                       Name of child (if applicable)

_________________________________                  ________________________ 

Print name of parent or guardian (if minor)                     Date

PERMISSION TO PHOTOGRAPH MY CHILD:

I HEREBY GIVE MY PERMISSION to Great and Small, a private, non-profit corporation, and its agents, volunteers and employees, to photograph my child while participating in the activities at Great and Small.  I understand that this picture may be used in Great and Small’s brochures or other written materials disseminated or available to the general public.  I am aware that Great and Small also serves children who have been adjudged to have been abused or neglected, or who come from an underprivileged background.  I further understand that my child’s name will not be used in any such written materials.

_________________________________                  ____________________________

Signature of parent or guardian (if minor)                       Name of child (if applicable)

_________________________________                  ________________________ 

Print name of parent or guardian (if minor)                     Date

BACKGROUND INFORMATION:

Have you ever been charged or convicted of a crime?       Y        N

I, ___________________________________________authorize Great and Small to receive information from any law enforcement agency, including police and sheriff departments, of the state or federal government to the extent permitted by state and federal law, pertaining to any convictions I may have had for violations of state or federal

criminal laws, including but not limited to convictions for crimes committed upon children.  I understand that such access is for the purpose con considering my application as a volunteer and that I expressly DO NOT authorize the operating center, its directors, officers, employees or other volunteers to disseminate this information in any way to any other individual, group, agency, organization, or corporation.

_________________________________                  ____________________________

Signature of parent or guardian (if minor)                       Name of child (if applicable)

_________________________________                  ________________________ 

Print name of parent or guardian (if minor)                     Date

DRIVER’S LICENSE NUMBER _____________________________________

State: ____________________