Volunteer Form Choose One * New Volunteer Returning Volunteer Random Background Checks may be required over the age of 18. I am interested in volunteering for the following. * Adaptive/Therapeutic Horseback Riding Office work(Requires fingerprinting) Barn Work, Cleaning stalls Fundraising -Assist Assist with working therapy horses Anything I can be helpful in! 4H Majestic Horse Spin Club- 6 weeks (fingerprinting required) Pet Paws & Inclusive 4H Program Name of Volunteer * First Name Last Name Nickname * or type N/A Volunteer’s Mailing/Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country County * Date of Birth * MM DD YYYY Sex (circle) * Male Female Other Cell Phone * (###) ### #### Home Phone * (###) ### #### Email School Name * or type N/A Other IF UNDER 18 YOU WILL NEED TO FILL IN TWO PARENTS OR GUARDIANS: CHOOSE ONE I am OVER 18 I am UNDER 18 I prefer that you contact me by: * Phone Call Text Email PHOTOS|MARKETING RELEASES Release For: Majestic Equine Connections, Inc.| I willingly accept photos/videos releases to be public for publicity purposes for Majestic Equine Connections, Inc. during participation in activities or on property for services. This may include but not limited to: Facebook, website, on news-television, magazine, instagram, display boards, Linkedin, audio/movie recordings, and/or any publicity purposes associated with Majestic Horse or Majestic Equine Connections, inc.. The purpose is for marketing the program and promotional reasons for grants, funding, enlisting new participants, and volunteers * YES, I agree NO, I do not agree Emergency Contacts are required for clients and volunteers in case of an emergency. Two Emergency Contacts are required and the 3rd is helpful if the first two do not answer the phone. Yes, you have my permission to call emergency services if there is an emergency. This will be an option if the caregiver or guardian is not listed above and is not available through a phone call. GUARDIAN/SELF SIGNATURE (Typing in your signature here will serve as your legal digital signature) * Date * MM DD YYYY Diabetes Alert? * Yes No Allergy Alert? * Yes No Seizure Alert? * Yes No Added Info (STUNTS) Or type N/A * First Name Last Name Insurance Name/#ID * Preferred Hospital * Date of Birth * MM DD YYYY PRIMARY DOCTOR & PH# * Health History:Confidential - Write health history (ex: Depression, Diabetes, arthritis, ect…) * Emergency Contact 1 (i.e. Parent) * First Name Last Name Em. Contact Phone 1 * (###) ### #### Em. Contact Phone 2 (or type N/A) * (###) ### #### Em. Contact 1 Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact 2 (i.e. Grandparent II) * First Name Last Name Em. Contact 2 Phone 1 * (###) ### #### Em. Contact 2 Phone 2 * (###) ### #### Em. Contact 2 Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact 3 (i.e. Aunt/Uncle) * First Name Last Name Em. Contact 3 Phone 1 * (###) ### #### Em. Contact 3 Phone 2 * (###) ### #### Em. Contact 3 Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Majestic Equine Connections, Inc. has two addresses. Please contact Jennifer for which address the service will be held. The Westfield Road address is TBA for equestrian activities. 1. Current Horse Activities Address: 7460 Wooster Pike Rd. Seville, Ohio 44273 2. Chippewa Lake House: 7859 Westfield Road Medina, Ohio 44256 - NEW A Partner with Medina County Parks District and The Ohio University Extension of 4H Spin Club. If you have read the statement and understand the addresses we operate out of type in "Yes" * CAUTION: READ CAREFULLY BEFORE SIGNING. ONE SIGNED COPY REQUIRED FOR EACH INDIVIDUAL WHO PARTICIPATES IN AN ACTIVITY. I agree to the following Waiver, Agreement, and Liability Release with Majestic Equine Connections, Inc. and/or affiliated persons associated with the equine activities (referred to herein as “The Property Owners (“Danny & Jennifer Stankiewicz”), as a condition for its allowing me, and the other persons identified below, to do any of the following: enter any premises or facility where equine activities are conducted, be near horses in connection with any equine activities (handling, grooming, near, or riding horses). Agreement regardless of whether these activities take place under the supervision of “The Property Owner and Lessee” and its affiliates Majestic Equine Connections, Inc..at the following addresses: 7460 Wooster Pike Rd. Seville, Ohio 44273 and 7859 Westfield Road Medina, Ohio 44256. CONTRACTING PERSON(S) PARTICIPANT'S NAME: * CONTRACTING PERSON(S) PARTICIPANTS NAME First Name Last Name Date of Birth * MM DD YYYY SIGNATURE (Typing in your signature here will serve as your legal digital signature) * Date * MM DD YYYY Home Phone/Cell * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Guardian Signature (Typing in your signature here will serve as your legal digital signature) * First Name Last Name Date * MM DD YYYY Additional Participants with same Guardian/Parent adding on: I also make this agreement of behalf of the following, who are my children or legal wards: If you have additional participants indicate YES. * Yes, I have additional participants No, I don't have additional participants All parts of the Waiver, Agreement, and Liability Release shall apply to me, and the children/legal wards listed above. (We will collectively call ourselves “I”, “me”, or “my”, throughout this agreement.) This Waiver, Agreement, and Liability Release will be binding at all times, now and in the future, even after my relationship with “The property Owner”. RELEASE STATEMENT I understand that parts of the activities may be physically or emotionally demanding. I affirm that I (or the participant) am in good health and am not under a physician's care for any undisclosed condition that bears upon my (or their) ability to participate in this activity. I understand that “The property Owner” will offer safety equipment such as helmets. I recognize the inherent risk or injury or disability and understand that each participant must assume the risk of physical injury that could result. I release “The property owners” and volunteers from liabilities resulting from participating in these activities. This release is governed by the State of Ohio. WARNING Under the Ohio Equine Activity Liability Act, (Ohio Revised Code Chapter 2305.321) an equine professional is not liable for an injury or the death of a participant in an equine activity resulting from an inherent risk of equine activity. It is mutually understood and agreed that the liability release set forth herein shall constitute a waiver of liability beyond the provisions of the Ohio equine activity liability act. By signing this agreement and liability release, I agree not to bring any claim or suit against “The property owner” or volunteers, affiliated persons, and others acting on their behalf on the basis of any exception in that law. It is my intention to release and hold harmless “The property owner” or persons affiliated and entities associated with “The property owner” to the fullest extent allowed under the law. HELMETS/HEADGEAR I agree to be fully responsible for my own safety at all times. “The property owner” has suggested that I buy and wear a properly fitted ASTM-STANDARD/SEI-CERTIFIED EQUESTRIAN helmet when riding or near equines. I am not relying on “The property Owner” to provide a certified helmet for me, to check any helmet or strap that I may wear, or to monitor my compliance with this suggestion at any time. LIABILITY RELEASE: As consideration for being to enter on property, to be near equines in connection with any “The property owner/lessee” activities (regardless of who owns the equines), and/or engage in any other activity involving horses/equines, whether or not under “The property owner” supervision, I agree to assume full responsibility for any and all bodily injuries or damages which I may sustain when engaging in these and other activities. The term “damages,” means, for example, medical expenses, losses incurred because of bodily injuries or property damages, and/or personal property damages. I, for my heirs, administrators, personal representatives or assigns, release and discharge “The property owner” and its affiliated persons, and others acting on their behalf of and from any and all claims, demands, damages, actions, omissions, suits, or causes and action (present and future), whether the same by known or unknown, anticipated omissions, suits, or causes of action (present or future), whether the same by known or unknown, anticipated or unanticipated, resulting from or arising out of my bodily injury or damage that may be sustained, or property damage which may occur as a result of being on the property, handling horses, being near horses, and/or engaging in any other activity involving horses, whether or not under “The property owner” supervision. It is my intention to RELEASE/WAIVER OR HOLD HARMLESS Danny & Jennifer Stankiewicz (“The property Owner” and Lessee) or persons AFFILIATED with equine activities and/or other animals at the following address: 7460 Wooster Pike Rd. Seville, Ohio 44273. 7859 Westfield Road Medina, Ohio 44256 EQUINE-RELATED RISKS: I understand that anyone riding, handling, or even near a horse (referred to as “equine”) can suffer bodily and other injuries. Among other things, equines are unpredictable by nature. For example, frightened, angry, or under stress, the natural instincts of an equine are to jump forward or sideways or run away from danger by trotting or galloping. Equines are also known to kick, buck, rear up, back up quickly, spin around, strike, or bite. I know that equines can do any of these things without warning. I also understand that all equines, even if they have no known history of hurting people or animals, are powerful and can be dangerous to people, and other animals. I fully read and agree with the above. PARTICIPANT'S NAME: * PARTICIPANT'S NAME: First Name Last Name SIGNATURE/OR GUARDIAN: (Typing in your signature here will serve as your legal digital signature) * First Name Last Name Date * MM DD YYYY Majestic Equine Connections, Inc. VOLUNTEERS BARN EXPECTATIONS Horse Activities Address: 7460 Wooster Pike Road Seville, Ohio 44273 Chippewa Lake House: 7859 Westfield Road, Medina, Ohio 44256 * Yes, I am 18 or older and willing to get a BACKGROUND Check within a reasonable time. No, I am not 18 or older. In order to achieve a safe atmosphere for our participants we must follow the guidelines below. Please check off all the boxes as you read them. * Please be on time! Some lessons are scheduled back to back. Our expectations are 30 minutes early for Horse leaders and Sidewalkers 15 minutes early. Majestic Equine Connections, Inc. (MEC) is a non-profit organization (501 c3) to serve persons with disabilities/diversity. Lessons CAN BE canceled depending on the weather. Please inform Jennifer on the best way to I prefer you to Call me and if I do not answer, please leave a message. All forms must be filled out which includes: Equine Waiver, Emergency Contact, Photo Releases, AND some health history if any concerns of performing volunteer job duties. Please be responsible for all of your belongings. Majestic Equine Connections, Inc. is not responsible for your belongings. Please do not run or wander in restricted areas. Ask if you are unsure. Helmets are required during lessons. It is the side walker's responsibility to assist participants with helmets. Please read all signs in your designated areas to adjust to any necessary changes in that AREA. Parking in the rear near a big yellow barn or near home. We are flexible. Please do not park anyone in. Please do not park in grass areas to prevent tire marks in grass. No dogs allowed, no weapons, no drugs, no smoking, no drinking alcohol or under the influence, and no anger. You are encouraged to Self-Care prior to arriving, eating, drinking, bringing fluids, wearing appropriate clothing and closed-toed shoes. Our participants are counting on you! I sign and agree to the barn rules. I understand that I am expected to complete the orientation prior to volunteering. Read and check off boxes! VOLUNTEER NAME * First Name Last Name Date * MM DD YYYY SIGNATURE OF SELF OR GUARDIAN: (Typing in your signature here will serve as your legal digital signature) * Background Information Must answer honestly. This is confidential. For ages of 18 years or older Have you ever been charged with or convicted of a crime? BCI check. * Yes No Do you have a driver's license? * Yes No STAFF PORTION: THIS BOTTOM PORTION TO BE SIGNED BY THE STAFF WHEN RECEIVED, PLEASE LEAVE BLANK AND MOVE TO THE NEXT QUESTION------------------- Confidentiality Agreement: I understand that all information (written/verbal) about participants at Majestic Equine Connections, Inc. 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. I,_________________________(volunteer/staff), authorized Majestic Equine Connections, Inc.| Executive Director to receive information from any law enforcement agency, including police department and sheriff’s departments, of this state (Ohio), 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 theft, children, elderly, or animals. (Information is confidential). I understand that such access is for the purpose of considering my application as an contractor/employee/volunteer. Authorization may NOT be limited to the Board of Developmental Disabilities due to their support and willingness to fingerprint our volunteers within the community. All information is kept in a locked location. Volunteer Signature:__________________________________Date:_______________------------------------- Have you filled out sections (except for the STAFF SIGNATURE SECTION ABOVE) and are ready to submit your application?) Please click yes and then submit. * Yes Thank you for signing up to volunteer!
