Volunteer Application Form

Volunteer Application
Thank you for your interest in our organization. So that we can best utilize your experience and interests, please complete this application form as fully as possible.
I. PERSONAL INFORMATION
Have you ever been affiliated with Second Chances as a volunteer or rider?*

YesNo
If Yes, when?*
Participant's DOB*

MonthDayYear
Name*

First NameLast Name
Parent/Guardian Name *

First NameLast Name
Parent/Guardian Phone Number*

Area CodePhone Number
E-mail*
Providing my email address allows Second Chances to send me program news, updates, information, and etc. This email shall remain the property of Second Chances and will not be sold or given to any third parties.
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
How did you first learn about Second Chances?

Radio/TVNewspaperInternetSchool/CollegeReferral
Please specify referring Organization/Individual/Other*

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
Applicant Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Medical Facility*
Physician's Name*

First NameLast Name
Physician's Phone*

Area CodePhone Number
Health Insurance Company*
Policy Number*
Allergies to Medications*
Current Medications*
Emergency Contacts:
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
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 Second Chances Equine Rescue Inc. to:
1. Secure and retain medical treatment and transportation if needed.
2. Release volunteer records upon request to the authorized individual or agency involved in the medical emergency treatment.
Consent Plan

I DO give authorization that may include x-ray, surgery, hospitalization, medication, and any treatment procedure deemed “lifesaving” by the physician. This provision will only be invoked if the emergency contact person(s) above is unable to be reached.
Signature
Parent/Guardian Signature
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. In the event emergency treatment aid is required; I wish the following procedures to take place:
Signature
Parent/Guardian Signature

SECOND CHANCES EQUINE RESCUE INC.

RELEASE OF LIABILITY
Signature*
Parent/Guardian Signature*
PHOTO AND VIDEO CONSENT
Signature*
Parent/Guardian Signature*
Should be Empty:

Volunteer Application

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

SECOND CHANCES EQUINE RESCUE INC.