GREENLOCK THERAPEUTIC RIDING CENTER, Inc.

55 Summer street – Rehoboth, MA  02769

Telephone:  (508) 252-5814

 

Specializing in hippotherapy treatment

& Offering therapeutic riding
 

 

 

 


Volunteer/Staff Information Form and Health History

 

General information

 

Name: _______________________________________________________________ Date: ________________________

Address: _________________________________________________________________________________________

Email Address:  ___________________________________________________________________________________

Employer/School: ___________________________________________________________________________________

Work Address: _____________________________________________________________________________________

Date of Birth: ________________ Phone: (H)__________________________ (W)_______________________________

Parent/Legal Guardian Name and Address: ________________________________________________________________

_________________________________________________________________________________________________

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)

 

Health History

 

Please describe your current health status, particularly regarding the physical/emotional demands of working in a

therapeutic riding program. Address fitness, cardiac, respiratory, bone or joint function, recent hospitalizations/surgeries,

or lifestyle changes.

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Allergies: _________________________________________________________________________________________

_________________________________________________________________________________________________

Medications: ______________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

 

 

Check which areas you are interested in:

 

 

Program

 

Special Events

 

 

Administrative

 

Horse handling

 

Horse Shows

 

 

Public Relations

 

Sidewalking with a client

 

Fundraising

 

 

Grant Writing

 

Therapist

 

 

 

 

Photography/Video

 

General Stable help

 

 

 

 

 

 

 

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.

 

Signature: __________________________________________________________ Date: ________________________

(volunteer/staff; signed in presence of center staff)

 

GREENLOCK THERAPEUTIC RIDING CENTER, Inc.

55 Summer street – Rehoboth, MA  02769

Telephone:  (508) 252-5814

 

Specializing in hippotherapy treatment

& Offering therapeutic riding
 
 


 

 

 

 

 

Volunteer/Staff Information Form and Health History - Page 2

 

Confidentiality Statement

 

 

Employee______         Volunteer______

 

As a condition of my involvement at Greenlock Therapeutic Riding Center, Inc. (GTRC), I hereby agree to the following:

 

Text Box: I will not, without GTRC's Director's written permission, disclose to anyone outside of GTRC any confidential information, or information concerning the clients or business of GTRC. I further understand and agree that if I release any confidential information referred to above, other than to other employees or volunteers of GTRC, or as directed by my Director, my employment or volunteerism may be immediately terminated. I also understand that this Confidentiality Statement neither expressly nor implicitly creates a contract for employment or volunteerism. My employment or volunteerism may be terminated, either by GTRC or myself, for any reason, at any time, with our without notice.

 


__________________________________________________________________________________________

Signature of Employee, Volunteer, Parent or Legal Guardian                                                             Date

 

 

__________________________________________________________________________________________

Witness

 

SOCIAL SECURITY # REQUIRED FOR STAFF ONLY:____________________________________________

 

 

 

PHOTO RELEASE

 

I ____ DO

  ____    DO NOT

 

consent to and authorize the use and reproduction by GREENLOCK THERAPEUTIC RIDING CENTER, INC.

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: ___________________________________________________ Date: ____________________

                           Employee, Volunteer,  Parent or Legal Guardian