MapleStone Farm
MapleStone Farm
Therapeutic Riding & Driving Center
A NARHA Premier Center
MapleStone Farm, LLC
2435 Milton Mills Rd.
Acton, ME 04001-5014
T (207) 477-2757
F (207) 477-2820
pat@maplestonefarmLLC.com
2435 Milton Mills Rd.
Acton, ME 04001-5014
2008 Season
Dear Prospective Volunteers,
Thank you for considering MapleStone Farm Therapeutic Riding and Driving Center for volunteerism. We strive to maintain a safe and proactive environment for both participants and horses.
Please find the following general application for 2008 and liability release forms. Please mail them to the address above and we look forward to hearing from you!
Sincerely yours,
Pat Pearson
MapleStone Farm
MapleStone Farm, LLC
2435 Milton Mills Rd.
Acton, ME 04001-5014
T (207) 477-2757
F (207) 477-2820
pat@maplestonefarmLLC.com
2008 VOLUNTEER APPLICATION
2435 Milton Mills Rd Phone: 207.477.2757. FAX: 207.477. 2820
Name______________________________ Date___________
Address ___________________________ Apt/Unit________
City_______________________________State/Zip________
Home Phone_______________________________
Work Phone______________________
Cell Phone ___________________
Email Address __________________________________
Employer_________________________________________________
Divers license Number and State:_____________________________
Have you been convicted of a felony in the last five (5) years no yes (Please explain on separate sheet)
I __________________ (volunteer/staff), authorize MSFTRC to receive information from any law enforcement agency, including police departments and sheriffs 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 the purpose of considering my application as an employee/volunteer, and that I expressly DO NOT authorize the NARHA center, its directors, officers, employees, or other volunteers to disseminate this information in any way to any other individual, group, agency, organization, or corporation.
Signature:____________________ Date:___________
(volunteer/staff)
Emergency Contact Information
Name Relation Phone ________
Name Relation
Phone ________
Health Profile & History
Medications:____________________________________
Date of last Tetanus shot: ________Date and Result of Tuberculosis Test ____________
** Please consult your physician or local health department if you are not up to date with these shots/tests.
MapleStone Farm
MapleStone Farm, LLC
2435 Milton Mills Rd.
Acton, ME 04001-5014
T (207) 477-2757
F (207) 477-2820
pat@maplestonefarmLLC.com
Please describe current health status (physical/emotional demands of working in an equine assisted program. Address fitness, cardiac, bone/joint function, recent hospitalization/surgery, medications or lifestyle changes.):
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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)
Availability:
Days of the week_________________________________
Time of Day: ___________________________________
Areas of Interest: Please Circle
Program Special Events & Trips
Side-walking w. student** History By Horseback Grant Writing
Stable Mgmt. Volunteer* Fun Day/Horse show Horse Handling
Exercise Rider++ Acadia Nat.’l Park Trail Rides
Fundraising
Budget/Finance
Facility Repairs
Future Planing
Volunteer Recruitment
*Must be 12 years of age
**Must be 14 years of age
++Must be 14 years of age, separate application and riding assessment required
EXPERIENCE
Tell us about your horse and/or riding experience, previous work at a therapeutic riding center, and/or experience with people with disabilities:______________________________________________________________________________________________________________________________________________________________
Have you or members of your family served or in the military? __________________________
MapleStone Farm
MapleStone Farm, LLC
2435 Milton Mills Rd.
Acton, ME 04001-5014
T (207) 477-2757
F (207) 477-2820
pat@maplestonefarmLLC.com
How did you hear of the Volunteer Program and why do you wish to volunteer? ______________________________________
REFERENCE
Please list one personal or business reference:
Name_____________________________
Phone_____________________________
Relationship________________________
2008 VOLUNTEER RELEASE OF LIABILITY
This RELEASE OF LIABILITY is made between MapleStone Farm Therapeutic Riding Center (MSFTRC) and the Volunteer, ________________________________________(hereinafter designated as VOLUNTEER)
As a volunteer at MSFTRC, I acknowledge the risks and potential for risks of a horseback riding program. However, I feel that the possible benefits to myself and the clients I work with are greater than the risks assumed. I hereby, intending to be legally bound, for myself as a participant, my heirs, parents, legal guardians, spouses, children, and assigns, executors or administrators, wave and release and hold harmless, forever all claims from damages or injuries against MSFTRC, Maplestone, MapleStone Farm, and its trustees, officers agents, its board of directors, instructors, therapists, volunteers, families, employees for any and all injuries and against all claims, demands, actions, and causes of action for damages which we may sustain or incur due to the personal injury, death, or property damage sustained by ________________________ and arising from his/her participation in the program or from the use of or presence upon MSFTRC’s property and facilities including, without limitation but not limited to, the risks of death, bodily injury, property damage, falls, kicks, bites, collisions with vehicles, horses or stationary objects, fire or explosion, the unavailability of emergency medical care, or the deliberate act of another person..
MapleStone Farm
MapleStone Farm, LLC
2435 Milton Mills Rd.
Acton, ME 04001-5014
T (207) 477-2757
F (207) 477-2820
pat@maplestonefarmLLC.com
As a volunteer I acknowledge the responsibility to carry full and complete insurance coverage of myself and agree that I shall furnish evidence of health insurance upon request of MSFTRC.
As a volunteer I agree to abide by all rules and regulations as they now exist or as they may be amended periodically. Furthermore, I agree to indemnify and defend MSFTRC against, and hold harmless from, any and all claims, causes of action, damages, judgments, costs or expenses, including MSFTRC attorney’s fees, which in any way arise from, or are associated with, volunteer’s use of or presence upon the MSFTRC’s property and facilities, or the use of or presence of my invitees and family members.
As a Volunteer I agree to waive the protection afforded by the Maine Revised Statutes Annotated, any Federal Laws and any common law whose purpose, substance and/or effect is to provide that a general release shall not extend to claims, material or other, which the person giving the release does not know or suspect to exist at the time of executing the release.
In signing below I acknowledge that I have read the above and have am legally bound to the aforementioned agreements and acknowledgements.
Date:________ Volunteer:____________________________________________
Date:________ MSFTRC Witness:_____________________________________
Date:________ Parents/ Guardians___________________________
Photo/Video Release I DO DO NOT
consent to and authorize the use and reproduction by MapleStone Farm Therapeutic Riding and Driving Center of any and all photographs and any other audio/visual materials taken of __________________________ for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
Signature____________________________________
(volunteer, parent or legal guardian)
Date___________