Volunteer/Staff Information Form and Health History
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Email *
GENERAL INFORMATION

Name

Date
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Address
Date of Birth
MM
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DD
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Phone (H)
Phone (W)
Employer/School
Employer/School Address
Parent/Legal Guardian/Caregiver Name/Address/Phone Number
How did you learn about the program?
Recent Medical tests
Last Tetanus Shot
Tuberculosis Test + - Date

(Consult your physician or local health department if you are not up to date with these shots/tests)

MM
/
DD
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YYYY
HEALTH HISTORY
Current Health Status
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 joint function, recent hospitalizations/surgeries or lifestyle changes.
Allergies
Medications
Check areas in which you are interested

Program

Special Events

Administration

I understand that 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. *
Name and Date (volunteer/staff/caregiver; signed in presence of center staff)
PHOTO RELEASE *

I consent to and authorize the use and reproduction by Horse Life Miami 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.

SIGNATURE *
Name and Date
Background Information
Have you ever been charged with or convicted of a crime? Y/N  - Please explain
ACCEPTANCE (Name) *

I (volunteer/staff), authorize Horse Life Miami to receive information from any law enforcement agency, including police departments and sheriff’s departments, of this state or any other 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 or animals.

I understand that such access is for the purpose of considering my application as an employee/volunteer, and I expressly DO NOT authorize Horse Life Miami, its directors, officers, employees or other volunteers to disseminate this information in any way to any other individual, group, agency, organization or corporation.

Confidentiality Agreement (Name) *

I understand that all information (written and verbal) about participants at Horse Life Miami is confidential and will not be shared with anyone without the expressed written consent of the participant and their parent/guardian in the case of a minor.

Date *
MM
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