<p> A Little Bit of Heaven Inc. Volunteer Application Packet</p><p>Please Print Clearly on All Forms</p><p>NAME______</p><p>DOB ____/_____/____ AGE______(must be 18 or over)</p><p>ADDRESS ______</p><p>CITY______STATE______ZIP______</p><p>Please provide both phone numbers and indicate your preferred contact number:</p><p> HOME PHONE ______</p><p> CELL PHONE ______</p><p>EMAIL ADDRESS: ______</p><p>MOST RECENT EMPLOYMENT/SCHOOL:______</p><p> My employer gives times off for volunteering</p><p> My employer has a matching donation program</p><p>REASON FOR VOLUNTEERING</p><p> Personal Fulfillment </p><p> School Requirement </p><p> Community Service </p><p> Other: ______</p><p>HOW DID YOU HEAR ABOUT A LITTLE BIT OF HEAVEN? </p><p> Friend/Relative</p><p> Publication </p><p> Local Event  Internet/Social Media</p><p> Other: ______</p><p>DO YOU HAVE ANY EXPERIENCE WITH HORSES?  Yes  No</p><p>VOLUNTEER INTERESTS (please check all that apply)  Working with horses, including riding</p><p> Side-walking or leading horses, not riding</p><p> Horse Care (grooming, tacking, etc.)</p><p> Barn Help (raking, sweeping, picking ring, etc.)</p><p> Facility Repairs (painting, etc.)</p><p> Photography/Video </p><p> Office Help (mailing, answering phones, volunteer intake)</p><p> Fundraising </p><p> Budget/Finance</p><p> Event Coordination </p><p> Other: ______A Little Bit of Heaven Inc. Volunteer Application Packet</p><p>Photo Release </p><p>I, ______, ____DO _____ DO NOT consent to A Little Bit of Heaven Inc.’s use and reproduction of any and all photographs and any other audio/visual materials taken of me for possible promotional materials, educational activities, exhibitions, of for any other use for the benefit of the by A Little Bit of Heaven Inc. </p><p>DATE ______</p><p>SIGNATURE ______Volunteer Medical History & Release/Authorization Information</p><p>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 A Little Bit of Heaven Inc. to secure and retain medical treatment and transportation if needed and to Release client records upon request to the authorized individual or agency involved in the medical emergency treatment. </p><p>Emergency Contact #1Name: ______</p><p>Contact Number:______</p><p>Emergency Contact #2 Name: ______</p><p>Contact Number:______</p><p>Preferred Medical Facility: ______</p><p>Health Insurance Provider:______</p><p>Policy#: ______</p><p>Allergies:______</p><p>Current Medications:______</p><p>______</p><p>CONSENT PLAN: This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “lifesaving” by the physician. The provision will only be invoked if the person(s) above is unable to be reached.</p><p>Consent Signature:______Date: ______</p><p>NON-CONSENT PLAN: I do not give my consent for emergency medical treatment/aid in the case of illness or injury during volunteer activities or while being on the property of A Little Bit of A Little Bit of Heaven Inc. Volunteer Application Packet</p><p>Heaven, Inc. In the event emergency treatment/aid is required, I wish the following procedure to take place: ______</p><p>______</p><p>Non-Consent Signature:______Date: ______A Little Bit of Heaven, Inc. Phn: (315) 276-5415 35 Hallahan Rd Fax: (315) 389-5415</p><p>North Lawrence, NY 12967 [email protected] www.alittlebitofheaveninc.org</p>