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? *

Yes No
If Yes, when? *
Participant's DOB *

Month Day Year
Name *

First Name Last Name
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Phone Number *

Area Code Phone 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 Code Phone Number
Address *

Street Address

Street Address Line 2

City State

Zip Code
How did you first learn about Second Chances?

Radio/TV Newspaper Internet School/College Referral
Please specify referring Organization/Individual/Other *

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
Applicant Name *

First Name Last Name
Date of Birth *

Month Day Year
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State

Zip Code
Medical Facility *
Physician's Name *

First Name Last Name
Physician's Phone *

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

First Name Last Name
Phone Number *

Area Code Phone Number
Name *

First Name Last Name
Phone Number *

Area Code Phone 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:

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Volunteer Application

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

SECOND CHANCES EQUINE RESCUE INC.