Name
*
First Name
Last Name
Mailing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
Phone
*
(###)
###
####
Email
*
Secondary Phone
(###)
###
####
Employer / School
Parent/Guardian/Caregiver Name/Address/Phone
How did you learn about the program?
*
Last Tetanus Shot
Please consult with your physician or medical department if you are not up do date in order to decrease risk.
MM
DD
YYYY
Health History
*
Please describe your current health status, particularly regarding the physical/emotional demands of working in an equine=assisted program. Address fitness, cardiac, respiratory, bone or join function, and recent hospitalizations/surgeries.
Allergies
*
Barn Buddies- tailored recreation and riding for children with disabilities. Volunteers MUST be able to commit to same day/time for 5 weeks at a time.
*
Stable Moments- non-riding mentorship of foster/adoptive children. Volunteers MUST be able to commit to same day/time for 4 months, preferably 10 months
*
Farm Crew. Volunteers MUST be willing to help out at least monthly and invest time in getting to know staff and animals.
*
Confidentiality Agreement
*
I understand that all information (written and verbal) about participant at this center is confidential and will not be shared with anyone without expressed written consent of the participant and his/her parent/guardian in the case of a minor.
Photo Release
*
I consent to and authorize the use and reproduction by Justin's Place of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
Please tell us about any previous horse experience.
Please tell us about any previous experience working with children and/or individuals with disabilities.
Potential Availability
Please let us know what times you MAY be able to volunteer.
T-Shirt Size
*
Youth L
Adult S
Adult M
Adult L
Adult XL
Adult XXL
By typing my name below I understand the information provided above is accurate to the best of my knowledge. I know of no reason why I should not participate in this center's program.
First Name
Last Name
By typing my name I am stating I have been provided a copy of Justin’s Place programming manual. I agree to abide by the provided guidelines and information while on the property.
Todays Date
*
MM
DD
YYYY
