H.E.L.P., Horse Empowered Learning Programs
2908-B East Howard Lane • Manor, Texas 78653 • www.helpcenterofaustin.org
Volunteer / Staff Information
Name:
Date of Application:
Date of Birth:
Age:
Gender:
Address:
City:
Primary Phone:
Secondary Phone:
Height:
State:
Weight:
Zip:
Email:
Contact Information
Parent/Legal Guardian/Caregiver:
Address:
Phone:
Employer/School:
Address:
Phone:
Referral Source (Name):
Military Service
Are you or any family member currently serving or have previously served in the United States Military?
___Yes
___No
Rank:
If yes, which branch?
Active, Discharged or Retired?
Relation to Client:
Past Equine Experience
Riding Experience: ___Western ___English
___Dressage
___Recreational
___Competitive
Number of Years Riding:
Have you volunteered at a therapeutic riding center before?
___Yes
___No
If yes, where?
When?
FOR OFFICE USE ONLY
Training Level:
Training Date:
Trainer Initials:
Training Level:
Training Date:
Trainer Initials:
Training Level:
Training Date:
Trainer Initials:
June 2014-SGP
Page 1 of 9
H.E.L.P., Horse Empowered Learning Programs
Staff/Volunteer Application
Name: ______
Health History
Environmental Allergies:
Do you have severe environmental allergies that could require epinephrine injections? ___Yes ___No
Date of 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 an equine assisted program. Address fitness, cardiac (including high blood pressure),
respiratory, bone or joint function (including back or knee problems), recent hospitalizations/surgeries,
cognitive functioning, or lifestyle changes.
I understand that the information provided above is accurate to the best of my knowledge. I understand
that participation in equine assisted activities can be physically demanding. I know of no reason why I
should not participate in equine assisted activities at H.E.L.P. Horse Empowered Learning Programs.
I further agree to inform H.E.L.P. of any changes in medical condition that could preclude my
participation in equine assisted activities.
Signature of volunteer/staff, parent or guardian
Jun 2014-SGP
Date
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H.E.L.P., Horse Empowered Learning Programs
Staff/Volunteer Application
Name: ______
Consent for Emergency Medical Treatment
Name:
Date of Birth:
Address:
City:
Physician’s Name:
Preferred Medical Facility:
Health Insurance Company:
Phone:
State:
Zip:
Policy #:
Allergies to Medications:
Current Medications:
In the event of an emergency, contact:
Name:
Relation:
Phone:
Name:
Relation:
Phone:
Name:
Relation:
Phone:
Consent Plan
In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving
services, or while being on the property of the agency I authorize H.E.L.P. Horse Empowered Learning Prograsm
to:
1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to the authorized individual or agency involved in the medical
emergency treatment.
This authorization includes x-rays, surgery, hospitalization, medication and any treatment procedure deemed “life
saving” by the physician. This provision will only be invoked if the person(s) above is unable to be reached.
Signature of volunteer/staff, parent or guardian
Date
Non-Consent Plan
I DO NOT give my consent for emergency medical treatment/aid in the case of illness or injury during the process
of receiving services or while being on the property of the agency.
___ Parent or legal guardian will remain on site at all times during the equine assisted activities.
___ In the event emergency treatment/aid is required; I wish the following procedure to take place:
Signature of volunteer/staff, parent or guardian
Jun 2014-SGP
Date
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H.E.L.P., Horse Empowered Learning Programs
Staff/Volunteer Application
Name: ______
Liability Release
I, _____________________________________, the undersigned staff/volunteer or parent/guardian of the
volunteer would like to participate in Equine Assisted Activities and Therapies (EAAT) at H.E.L.P.,
Horse Empowered Learning Programs.
I acknowledge the risks and potential for risks of equine activities. I understand that I or my child/ward
will be working with and around the horses of H.E.L.P. I, the undersigned adult client or parent/guardian,
hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrator, waive
and forever release, acquit, discharge and hold harmless all claims of damages against H.E.L.P., its board
of directors, trustees, agents, instructors, instructors in training, therapists, employees, representatives,
volunteers, owners of property on which H.E.L.P. operates, successors or assigns.
I understand that under TEXAS EQUINE LIABILITY ACT (Chapter 87, Civil Practice and Remedies
Code), an equine professional is not liable for an injury to or the death of a participant in equine activities
resulting from the inherent risks of equine activities.
Signature of volunteer/staff, parent or guardian
Date
Photo Release
I ___ DO ____ DO NOT consent to and authorize the use and reproduction by H.E.L.P., Horse
Empowered Learning Programs of any and all photographs and any other audio/visual materials taken of
me or my child/ward for promotional material, educational activities, exhibitions or for any other use for
the benefit of the program.
Signature of volunteer/staff, parent or guardian
Date
Confidentiality Agreement
I understand that all information (written and verbal) about participants at H.E.L.P. Horse Empowered
Learning Programs is confidential and will not be shared with anyone without the expressed written
consent of the client and his/her parent or legal guardian. I have received a copy of the Confidentiality
Policy. I understand and agree to abide by the rules set forth in the Confidentiality Policy.
Signature of volunteer/staff, parent or guardian
Jun 2014-SGP
Date
Page 4 of 9
H.E.L.P., Horse Empowered Learning Programs
Staff/Volunteer Application
Name: ______
Background Check
I,______________________________________, authorize H.E.L.P., Horse Empowered Learning
Program 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 is for the purpose of considering my application as an
employee/volunteer, and I expressly DO NOT authorize H.E.L.P., Horse Empowered Learning Program,
its directors, officers, employees, ot other volunteers to disseminate this information in any way to any
other individual, group, agency, organization, or corporation.
Signature of volunteer/staff, parent or guardian
Date
Current Driver’s License Number:
State:
FOR OFFICE USE ONLY
Background Check Completed: ___Yes
___No
Background Check Cleared:
___No
Jun 2014-SGP
___Yes
Date:
Page 5 of 9
H.E.L.P., Horse Empowered Learning Programs
Staff/Volunteer Application
Name: ______
Center Policies & Procedures
1. Attendance. In the event you will not be able to attend your regularly scheduled volunteer classes,
please contact the instructor as soon as possible.
a) If volunteer is under 18 years of age or has a legal guardian, a designated adult must be on the
premises at all times with the volunteer unless prior approval has been obtained.
b) Unsupervised children are not allowed at H.E.L.P. Children must be supervised at all times while
on H.E.L.P. premises.
2. Weather Policy. If temperature plus humidity is over 150 degrees, or if the temperature drops below
35 degrees, ground lessons may be administered at the instructor’s discretion.
a) Classes are automatically cancelled in the event of a National Weather Service Warning for
Travis County at the time of the scheduled session.
b) Classes are automatically cancelled in the event of Class Cancellations Due to Inclement Weather
for Pflugerville Independent School District.
c) In the event of a class cancellation due to inclement weather, H.E.L.P. will notify the
volunteer/staff by phone. It is the responsibility of the volunteer/staff to assure that H.E.L.P. has a
current phone number for notification purposes.
3. Volunteer/Staff Documentation. Volunteers/staff will be required to sign a variety of forms,
including but not limited to a photo release, liability release, and emergency medical forms PRIOR to
participation in equine activities.
4. Dress code. Volunteers/staff should dress appropriately for equine activities. This includes, but is not
limited to comfortable CLOSED TOE, CLOSED BACK shoes, weather appropriate attire, sunscreen,
etc.
a) Volunteers/staff will not wear revealing clothing, or clothing advertising drugs, alcohol, gang
colors, sexual content or other inappropriate subject matter.
5. Pets. PERSONAL PETS ARE NOT ALLOWED ON H.E.L.P. PREMISES, with the exception of
service animals.
6. NO SMOKING ON H.E.L.P. PREMISES.
7. Drugs and Alcohol. Volunteers/staff will not bring alcohol or drugs onto H.E.L.P. premises or be
under the influence of alcohol or drugs while on the premises.
8. NO WEAPONS of any kind are permitted on H.E.L.P. premises.
9. Photography. Permission must be obtained from the client, parent, instructor, and volunteer before
photos or video are taken.
10. Authorized Personnel Only Areas. Only staff, volunteers and clients with supervision will be allowed
beyond designated visitor areas. Off limit areas include, but are not limited to, horse tacking area,
mounting area, horse stalls, barn, tack room, arena, trails and pastures. H.E.L.P. staff and volunteers
will strictly enforce this rule.
11. Private Property. H.E.L.P. is private property. There is no admittance outside of operating hours
unless prior authorization has been received.
Jun 2014-SGP
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H.E.L.P., Horse Empowered Learning Programs
Staff/Volunteer Application
Name: ______
12. Texas Law. As of September 1995, Texas enacted the following law.
Texas Law (Chapter 87, Civil Practices and Remedies Code), an equine professional is not
liable for the injury to or death of a participant in equine activities resulting from the inherent
risks of equine activities.
13. Never hand feed the horses.
VIOLATION OF ANY OF THESE RULES MAY RESULT IN IMMEDIATE TERMINATION FROM
THE PROGRAM.
I have read, understand and agree to follow the policies and procedures set forth by H.E.L.P., Horse
Empowered Learning Programs.
Signature of client
Date
Signature of parent or legal guardian (if client under 18 years of age)
Date
Jun 2014-SGP
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H.E.L.P., Horse Empowered Learning Programs
Staff/Volunteer Application
Name: ______
Confidentiality Policy
I. General Principles. Clients and their families have a right to privacy that gives them control over the
dissemination of their medical or other sensitive information. H.E.L.P., Horse Empowered Learning
Programs shall preserve the right of confidentiality for all individuals in its programs.
II. Information Covered by the Confidentiality Policy. Information covered under this Confidentiality
Policy includes all personal information, including but not limited to, medical, financial, social, academic
and other sensitive information. All staff and volunteers must maintain the confidentiality of such
information regardless of how it is obtained. Disclosures may occur because a chart, record or computer
screen is left unattended. A volunteer or staff member may overhear a discussion or a third party or
family member may give the information. This kind of information is PROTECTED and volunteers and
staff who receive this information must not disclose it to anyone else without the express written consent
of the client or parent/guardian. All volunteers and staff shall keep confidential all medical, social,
referral, personal and financial information regarding a person and his/her family.
III. Persons Subject to the Confidentiality Policy. Anyone who works or volunteers for, or provides
services to H.E.L.P., Horse Empowered Learning Programs is bound by this policy. This includes but is
not limited to:




Full or part time staff
Independent contractors
Volunteers
Board members
IV. Competency and Informed Consent Disclosure. A client may not be competent to give consent for
disclosure of medical or sensitive information or both (including photographs and videotapes) because of
age or mental capacity. As a general rule, infants and children under the age of 18 do not have legal
authority to consent to disclosure. Only parents, legal representatives or others defined by state statute
generally have this authority.
Adults with developmental disabilities are presumed legally competent to give or deny consent to
disclosure unless they have been adjudicated incompetent to make this kind of health care decision. If a
substitute decision-maker has been appointed, specific and informed written consent should be obtained
from that individual. Volunteers and staff should not assume clients are or are not legally competent to
give or deny consent. Volunteers and staff should always refer to the instructor for permission to disclose
information or take photographs or videotapes.
V. Intra-Agency Access To and Disclosure of Medical and/or Sensitive Information. H.E.L.P., Horse
Empowered Learning Programs does not permit access to, or disclosure of, confidential medical
information without the client’s legal consent based on a perceived need to protect staff or volunteers
from possible exposure through casual contact.
Jun 2014-SGP
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H.E.L.P., Horse Empowered Learning Programs
Staff/Volunteer Application
Name: ______
Casual contact poses no risk of transmission of diseases such as HIV. The most effective method of
protection for situations in which staff or volunteers may be exposed to the blood of a participant is the
use of infection control procedures. These procedures should be used with all clients, volunteers or staff
under the assumption that all participants may have HIV, hepatitis or other blood borne diseases.
Knowledge that a particular participant has HIV infection does not protect others from transmission.
Using universal precautions does.
Notwithstanding this Confidentiality Policy, staff and instructors will provide appropriate guidance and
protection to volunteers regarding managing clients who may have emotional or behavioral challenges.
Such guidance will be provided with the minimum amount of disclosure of confidential client information.
In any event, such information revealed to the volunteer or staff member will be considered confidential
and will be protected under this policy.
VI. Extra-agency Disclosure of Medical and/or Sensitive Information. Disclosure or receipt of
confidential information to/from an outside agency or individual is strictly prohibited without the
expressed written consent of the client or parent/guardian.
VII. Penalties for Unauthorized Disclosure. Penalties will be levied on an individual volunteer, contractor,
staff member, or board member in the event of a breach of confidentiality. Such penalties may include:




Reprimand
Loss of certain job duties and/or responsibilities
Termination of employment
Dismissal of volunteer
Jun 2014-SGP
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