Please Print Form and Mail to Jacobs Ladder @ 5866 Bradford Rd. N Hahira, GA 31632
 
Volunteer/Staff Information Form and Health History
Name:
Date of Birth
Address:

How did you hear about the Program?
 
Contact_Numbers:

Phone:
Work number:
Employer/School:
Address:
Phone:
Parent/Legal Guardian:
Address (if different from above):
Phone(if different from above):
Referral Source:
Recent medical test:
Last Tetanus Shot:
Tuberculosis Test
Date:
(Consult your physician or local health department if you are not up to date with these shots/tests)
 
Health History:
Please describe your current health status, particularly regarding the physical/emotional
demands of working in a therapeutic riding program. Address fitness, cardiac, respiratory,
bone or joint function, recent hospitalizations, or lifestyle changes.
 
 
:
Medications:
Check which areas you are interested in:
 
          Program Volunteer Competition
Administration
Leading a horse Horse Show Public Relations Photography/Video
Sidewalking with a student Away Horse Shows Fundraising Budget & Finance
Stable management Ride-A-Thon Newsletter Future Planning
Facility Repairs Special Olympics Volunteer Recruitment    
 

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 operating center's program.

I do understand Name:
 
Todays Date:
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