First Name

Last Name

Address 1

Address 2

City

State
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Email

Cell Phone

Work Phone

Ext.

Date of Birth

Age

Employer/School

Occupation

City

State
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Underage Volunteer

If you are under the age of 18 years old, your parent/guardian must complete the following:

First Name

Last Name

Address 1

Address 2

City

State
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Home Phone

Alternate Phone

Parent/Guardian Signature

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Photo Release

I consent to authorize the use and reproduction by Heaven’s Gait Ranch, Inc. of any and all photographs and any other audio/visual/media materials taken of me for promotional material, educational activities, and exhibitions or for any other use for the benefit of the program.

Volunteer Signature

Date

Parent/Guardian Signature

Date

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Volunteer Health History

Do you have health issues or limitations that we should be aware of?
YesNo

If yes, please list:

Medications:

Height

Weight

Allergies

Describe your current health status, particularly regarding the physical/psychological/social/emotional demands of working in an equine-assisted program serving individuals with special needs and disabilities. Address fitness, cardiac, respiratory, bone or joint function, hospitalizations, surgeries, mental health concerns, or lifestyle changes:

Do you have any underlying medical conditions that may increase the risk of severe illness from COVID-19? HGR reserves the right to accept or deny volunteers on site based on risk factors outlined by the Centers for Disease Control & Prevention (CDC):

Are you 65 years or older?
YesNo

Do you live in a nursing home or long-term care facility?
YesNo

Do you have any of the following underlying medical conditions, particularly if not well-controlled, including: (select all that apply)
NoneChronic lung diseaseHeart conditionsDiabetesChronic kidney disease undergoing dialysisLiver diseaseConditions causing you to be immunocompromised

*Note: Many conditions can cause a person to be immunocompromised, including : (select all that apply)
Nonecancer treatmentsmokingbone marrow or organ transplantationimmune deficienciespoorly controlled HIV or AIDSprolonged use of corticosteroidsProlonged use of other immune weakening medications

Severe Obesity:
Note: Obesity is diagnosed when your body mass index (BMI) is 30 or higher.

To determine your body mass index: Divide your weight in pounds by your height in inches squared and multiply by 703.

Do you have a body mass index (BMI) of 40 or higher? (check only one)
BMI below 18.5 = underweightBMI between 18.5-24.9 = NormalBMI between 25.0-29.9 = OverweightBMI 30.0 and above = Obese

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Volunteer Authorization for Emergency Medical Treatment

In the event emergency medical aid/treatment is required due to illness or injury during the process of volunteering, or while being on the property of the agency, I authorize a representative of Heaven’s Gait Ranch, Inc. to secure and retain medical treatment and transportation if needed. In the event of an emergency, please notify:

First Contact

First Name

Last Name

Phone

Relationship to Volunteer:

Second Contact

First Name

Last Name

Phone

Relationship to Volunteer:

Third Contact

First Name

Last Name

Phone

Relationship to Volunteer:

Insurance Information

Health Insurance Co:

Policy #:

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Volunteer Liability Release

As a volunteer of Heaven’s Gait Ranch, Inc.: I acknowledge the risk and potential for risks of equine-assisted activities and therapies. However, I feel that the possible benefits of 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 damage against Heaven’s Gait Ranch, Inc., its Board of Directors, instructors, therapists, volunteers, participants, and/or employees for any and all injuries and/or losses I may sustain while participating in the programs of Heaven’s Gait Ranch, Inc. I understand that all information (written, observed, and/or verbal) about participants at this center is confidential and will not be shared with anyone outside the center without written consent from center management.

Volunteer Signature

Date

Parent/Guardian Signature (if volunteer is under 18 years old)

Date

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Volunteer Liability Release

Have you ever been charged with or convicted of a crime?
YesNo

If yes, please explain.

I, (volunteer name), authorize Heaven’s Gait Ranch, Inc. 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 animals or children.

I understand that such access is for the purpose of considering my application as a volunteer, and I expressly DO NOT authorize the PATH Intl. 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

Date

Do you have a current driver’s license?
YesNo

License Number:

State
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

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Confidentiality Agreement

I understand that all information (written, observed, and/or verbal) about participants at Heaven’s Gait Ranch, Inc. is confidential and will not be shared with anyone without the expressed written consent of the participant and his/her parent/guardian in the case of a minor.

Signature

Name

Date

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Volunteer Opportunities & Areas of Interest

Please check all areas of interest so we can best match your interests with the program’s needs.

Programs

Choose Programs You're Interested In
Horse HandlingGrooming and Tacking before lessonsSide walking in lessonsLead walking in lessons

Other (List):

Special Events

Choose Special Events You're Interested In
Special Event Planning CommitteesSeek Donations for EventsHorse Shows and Rider EventsBenefit Golf OutingsParades5k EventsCoordinating Social Events for VolunteersCooking/Baking for Events

Other (List):

Administration

Choose Administration You're Interested In
Public RelationsGrant WritingNewsletterVolunteer RecruitmentPhotographyVideoBudget and FinanceFuture Planning

Other (List):

Maintenance

Choose Maintenance You're Interested In
Grounds MaintenanceStable ManagementHayCarpentryFacility Repairs

Other (List):

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Lesson Volunteer Availability

Please select the days and times you would prefer to volunteer as a lead walker or side walker.

Monday
1:30-2:15 pm2:30-3:15 pm3:30-4:15 pm4:30-5:15 pm5:30-6:15 pm

Tuesday
1:30-2:15 pm2:30-3:15 pm3:30-4:15 pm4:30-5:15 pm5:30-6:15 pm

Wednesday
1:30-2:15 pm2:30-3:15 pm3:30-4:15 pm4:30-5:15 pm5:30-6:15 pm

Thursday
1:30-2:15 pm2:30-3:15 pm3:30-4:15 pm4:30-5:15 pm5:30-6:15 pm

Sometimes volunteers are unable to make it to Heaven’s Gait Ranch because of an unusual conflict in their typical schedule. In the event that our volunteers short handed, and your schedule allows some flexibility, please put an asterisk* next to the day and time you would be willing to fill in for somebody.

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