Volunteer Emergency Medical Release

Dream Quest EFP & TR, Inc.

Volunteer Information and releases

Volunteer Name: ______Date______

Home Phone: ______Work Phone:______Cell Phone: ______

Address: ______

Date of Birth: ______Email: ______

In Case of Emergency please contact:

Name:______Relationship to volunteer:______

Home Phone: ______Work Phone:______Cell Phone:______

Name:______Relationship to volunteer:______

Home Phone: ______Work Phone:______Cell Phone:______

Physician: ______Phone(s): ______

Medical issues of concern:______

Hospital preference: ______

Medical Release:

In case of emergency, I give permission to Dream Quest EFP & TR, Inc.and Happy Mama Farm to secure medical treatment including x-ray, surgery, hospitalization, andmedication.

Date:______Signature (parent if minor): ______

Photo Release:

I consent to and authorize the use and reproduction by Dream Quest EFP & TR, Inc. and Happy Mama Farm of any and all photographs and any other audio visual

materials taken of me for promotional material, educational activities, exhibitions, web site or for any other use for the benefit of the program.

Date:______Signature (parent if minor):______

CONFIDENTIALITY AGREEMENT:

Information regarding students and clients of Dream Quest Equine Facilitated Psychotherapy & Therapeutic Riding (DQ EFP & TR), Inc. is highly privileged and confidential. Additionally, all persons associated with DQ EFP & TR, Inc. have a right to privacy that gives them control over the dissemination of their medical history or other sensitive information. All medical, social, referral, personal, and financial information regarding any person and his/her family shall remain confidential.

DQ EFP & TR staff, board members, volunteers, parents, students and clients are required to preserve the right of confidentiality of all individuals in its programs.

It is the responsibility of all persons involved at DQ EFP & TR, Inc. to adhere to the privacy and confidentiality of all students and clients. Breach of the confidentiality policy may result in reprimand, loss of certain responsibilities or privileges, or termination of employment.

Date:______Signature:______

RELEASE OF LIABILITY

I,______, hereby agree to abide by the terms of this Release, and I agree more specifically that I release Dream Quest EFP & TR, Inc., and Happy Mama Farm and their agents, from any liability from all present and future claims arising from personal injury or property damage sustained by me or my minor children during the visitation of a horse or for any reason at Happy Mama Farm, whether or not the loss, damage or injury resulted from my own actions or that of another.

I,______, agree that I understand that any farm activity involves specific risks of property damage or personal injury to me or to my minor children arising from approaching, handling, grooming, mounting, riding, and dismounting a horse and from observing or participating in horse or farm activities.

I,______, agree that I understand that by signing this release that I hereby waive my right to file and promise not to file any legal proceedings against Dream Quest EFP & TR, Inc., Dream Quest EFP & TR Board members, Happy Mama Farm, Kay Watson, Margaret and Richard Korges or their agents, for any personal injury of property damage sustained by me or my minor children during any equine

related activity.

I,______, agree that in the event that any part of this Release should by adjudged invalid or unconstitutional, such adjudication shall in no manner affect the other parts, which shall remain in full force and effect as if the parts so declared or adjudged invalid were not originally a part hereof.

I,______, certify that by my signature below, I have read the foregoing release, and being of sound mind and an adult, sign it freely with full knowledge of its meaning and content.

WARNING

UNDER GEORGIA LAW, AN EQUINE ACTIVITY SPONSOR OR EQUINE

PROFESSIONAL IS NOT LIABLE FOR ANY INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISK OF EQUINE ACTIVITIES, PURSUANT TO CHAPTER 12 OF TITLE 4 OF THE OFFICIAL CODE OF GEORGIA ANNOTATED.

This:_____ day of ______, 20____.

Signed:______(Parent if minor)

Witness:______

Rules for Dream Quest Volunteers at Happy Mama Farm

Wear correct equestrian clothing – boots, long pants, appropriate shirts. During the summer, long shorts may be worn. Individuals wearing flip flops or sandals will not be allowed to volunteer. No dangling earrings or necklaces.
No cell phones during the lesson or session.Please turn off notification sounds. Help students or clients stay focused on the instructor or therapist.
Follow the directions of the Dream Quest staff. If you have a question or concern, please ask staff after the lesson or session, unless there is an immediate safety concern.
Always stay in the area around the barn or arena.

5.Arrive for lesson or sessionup to 30 minutes before it is scheduled.Plan to stay until after the lesson or session to help get things cleaned up.

6. ONLY adults or volunteers 16 years old or oldershould open and close the gate!

7.When you open the gate, use the rope tie to hold it in place as you progress through the gate or have someone stand behind the gate and hold it. NEVER stand or swing on the gate.

8.CLOSE THE GATE!! This is VERY important for the safety of all animals and people! (Never lock the padlock!)

9.Travel at 5 MPH and park in the lot beside the barn unless directed otherwise.

10.No smoking.

11.No pets.

12. Keep all information about students or clients CONFIDENTIAL!

______

Signature of volunteerDate

August 2017