Volunteer Application

Welcome!

We are excited you are interested in learning about our programs at Healing Strides! Please take the time to read through each release, so you fully understand. If you have any questions along the way, please reach out to our office at (540)334-5825.

This is for volunteering at Healing Strides.
This form must be completed in its entirety to go beyond our general area for the public. We apologize for the length but all is required to volunteer with us.

Who are you filling this form out for? *

Basic Info

We use an online management tool for helping to communicate with all our contacts (we will NEVER sell or share your personal information!).

If you are filling this out for MULTIPLE dependents/children, you will need to fill a form out for EACH one individually (NOTE the email section below).

This info will be used to communicate program updates, special events, fundraisers and other important info from Healing Strides.

Make sure you have access to both the email account and the mobile for future contact. If you unsubscribe, we will no longer be able to communicate with you via emails and phone (this includes billing, scheduling, weather related closing, etc.). We CANNOT sign you back up once you unsubscribe.

First Name (self/child/dependent) *

Last Name (self/child/dependent) *

Nickname or preferred name for self/dependent/child:

Name (first & last) of guardian/parent of the above dependent/child:

Phone for self/guardian/parent of dependent/child listed above: *

I consent to receive SMS notifications, alerts & occasional marketing communication from Healing Strides. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Note: Please be aware of the directions given below about the same emails, for different people. Our system will see the same email as the SAME person and we will loose your data for multiple dependents/children.

Please do not reuse the same email for multiple dependents/children.

Option 1: EMAIL: STOP if you are filling this out for multiple dependents/children, DO put an email here ONCE (first time only), then leave this (option 1) blank for any additional dependents/children forms. On the next dependent/child's form, complete OPTION 2 (DIRECTLY BELOW) for any additional forms you complete (even if this is for you as your own form). If you are filling this out for yourself (and no one else!), please put your Email here and a name in option 2-

Please be sure you have access to this email, we will be sending next steps. (check you spam)

Option 2: If filling this form out for child/dependent, what is the NAME of GUARDIAN/PARENT and a good email here (do not put your email in the section above if you are filling this out for MULTIPLE dependents/children or addtonally yourself). If this is for yourself (and no other forms for others), please put your name *

Date of birth (self/child/dependent) *

Gender (self/child/dependent) *

Address *

Additional Address Info

City *

State *

Postal code *

Country *

Photo & Publicity Release

I consent to and authorize the use and reproduction by Healing Strides of VA of all photographs and any other audiovisual materials taken of myself/dependent(s)/Child(ren) for promotional material, educational activities, exhibitions, or for any other use for the benefit of the program.

Photo & Publicity Argreement Release *

Yes, I CONSENT to release my/my dependent/child photos/videos.

No, I DO NOT CONSENT to release my/my dependent/child photos/videos.

By checking one of these boxes you are agreeing to the statement selected.

Emergency Contact

Emergency Contact Name for myself/dependent/child *

Please enter First and Last Name of contact

Emergency Contact Relation to myself/dependent/child *

Emergency Contact Phone *

Please include Area Code in phone number.

Medical Waiver and Health Information

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving/giving services, or while being on the property of HSVA or activity site, I authorize Healing Strides of VA to: 1) Secure and retain medical treatment and transportation if needed. 2) Release client records upon request to the authorized individual or agency involved in the medical emergency treatment. This authorization includes X-Ray, hospitalization, medication and any treatment procedure deemed "life-saving" by the physician. This provision will only be invoked if the person consenting below is non-responsive in a medical emergency.

Medical Waiver and Health Information *

I agree to the Medical Waiver and Health Information statement above.

By checking this box, you are agreeing to the waiver above.

Pre-existing Health Conditions for self/dependent/child (put n/a if none) *

Please list any pertinent medication(s) you/dependent/child are taking (including medical marijuana) (put n/a if none) *

Please note any allergies and if EpiPen or inhaler is used (put n/a if none) *

What is your/dependent/child general health status? Tell us about any special needs or health concerns (ex. bad back, cannot be on feet long periods, etc.) *

Do you/dependent/child have health insurance?

Insurance Details - please put company and coverage dates

General Liability Release

As a participant with Healing Strides of VA, I acknowledge and understand the risks and potential risks of a horseback and horse related activities in our program including but not limited to, (i) the propensity of an equine to behave in dangerous ways, which may result in injury or death to the participant or damage to property; (ii) the inability to predict an equine's reaction to sound, movements, objects, persons or animals; (iii) hazards of surface or subsurface conditions whether known or unknown; (iv) the condition and age of the equipment or tack, however, I feel that the possible benefits to myself and the participant I work with are greater than the risk I assume. I hereby, intent to be legally bound, for myself, my heirs and assigns, executors or administrators, and waive and release forever all claims for damages against-Healing Strides of VA, their board of directors, instructors, therapists, aides, volunteers, employees and their respective families, for any and all injuries and/or losses I may sustain while participating in Healing Strides of VA. I further certify that the foregoing statements and representations are being made by me knowingly, freely and voluntarily, and I understand that Healing Strides of VA is expressly relying upon the foregoing statements and representations in permitting me to participate in programs at Healing Strides of VA.

General liability Release *

I agree to the General Liability Release statement above.

By checking this box, you are agreeing to the Liability Release statement above.

Background Check Information

Have you/dependent/child ever been convicted of a crime? *

If you/they have been convicted, please explain below:

In the last 7 years, have you/the dependent/child been involved in any incidents of workplace misconduct, such as harassment, violence, or theft (as employee, volunteer, or contractor)? *

If yes to being involved in workplace misconduct, please explain in detail:

Have you/the dependent/child ever been the subject of a founded (substantiated) child abuse or neglect investigation (in VA or elsewhere)? *

If yes to being being a subject of a founded (substantiated) child abuse/neglect investigation, please explain:

Have you/the dependent/child ever been convicted of, pled guilty/no contest to, or been adjudicated delinquent for any felony or misdemeanor offense (including in VA or other states)? *

If answered yes to being convicted of, pled guilty/no contest to, or been adjudicated delinquent for, please explain (to include offense, date, and outcome) :

Background Check Consent

Background Check Consent: I consent to a background check by Healing Strides of Virginia (or its authorized third-party provider) to ensure program safety. This may include criminal history, sex offender registry, and other relevant screenings. Information will be used solely for eligibility determination and kept confidential per our Privacy Policy. I understand I may be denied participation if results indicate risks, and I have the right to review/dispute findings. Results will be retained for 7 years or as required by law. *

I consent to background check as needed.

(If no consent, note: Volunteering at Healing Strides will not be allowed.)

By checking this box you consent to an electronic signature where required in form: *

I consent to Electronic Signature for myself/dependent/child

Signature for consent to background check: *

Clear

Confidentiality

ACKNOWLEDGMENT OF HSVA CONFIDENTIALITY POLICY

* Due to the nature HSVA's programs, we are entrusted with sensitive personal information. Our clients are entitled to assurance of protection from unwarranted invasion of personal privacy. The Privacy Act, State and Federal Laws, regulations from licensing agencies and our basic constitutional rights are designed to protect us all from unwarranted invasion of privacy.

* No information about a client, including enrollment or residence, in written or any other form, may be disclosed to any person or organization without proper authorization. (The only exception is in a life-threatening emergency, in which necessary medical information may be disclosed to emergency personnel to expedite treatment). HSVA staff is responsible for reviewing all requests for information to ensure that the proper authorization has been obtained.

* Again, our records contain sensitive client information, which is protected by law from unauthorized disclosure. HSVA holds the moral and legal obligation to protect the interests of both our clients and employees. By signing the confidentiality agreement, I commit to protect the privacy of HSVA clients, both past and present.

* I have read the above and agree to maintain this policy during and after my tenure with HSVA. I realize that this document will become a permanent record at HSVA. I further realize that failure to comply with the policies on confidentiality could impact my involvement at HSVA.

Consent to Electronic Signature

Signature of Individual (18 years or older)/Parent/Guardian for the above described dependent/child *

Clear

Volunteering Information

We love our Volunteers and cannot do what we do without YOU. We had over 14,000 hours of volunteer services in 2023! You do not need to have horse experience. WE will teach you.

Volunteers are people who give their time and services to benefit our programs. Some bring skills in horsemanship, while others bring skills in leadership and other experiences. Our volunteers make a difference in the lives of others. They are the heart of our programs and their dedication to our mission is the reason why we thrive.

Volunteers Must: Be willing to attend appropriate volunteer training. Be committed to volunteering at your scheduled time at least once a week per 10 week session. (we need a commitment). We do not have an age requirement but a level of maturity is expected and all youngsters MUST be accompanied by an adult/parent/guardian who will be responsible for them while volunteering.

It is up to the staff of Healing Strides to determine if any volunteer is a good fit for the responsibilities that are asked of them.

By checking this box, you are stating you have read and agree to the above volunteer information: *

Check here

Why do we need this info? Some volunteering roles and duties might require you to work with larger horses, carry heavier things, etc. We also work with Participants that have many different needs and the below information helps us make more informed decisions for our Participants and Volunteers. Please fill out whatever info you are comfortable sharing with us.

T-Shirt Size

Experience and Health

Do you have any previous horse experience? *

Enter your School or Employer name *

Do you have any health related concerns that we may need to know about? *

Ex. bad back, limited mobility, lifting restrictions, etc.

Volunteering is a powerful force that not only transforms the lives of those we serve but also enriches our own. It is through the selfless act of giving that we discover the true essence of community and compassion. By contributing our time and skills, we become instrumental in creating positive change and fostering a sense of unity.

Reason for Volunteering *If COURT ordered community service, please contact our office for approval. Not all are accepted.

How did you hear about volunteering with us? *

Do you have any special skills or training? *

Marketing, advertising, promotions and social media

Special event planning, auction planning, procurement

Fencing, electrical, and building repairs or maintenance

Data entry

Other

What does "other" mean?

Captcha

If the submit button does not work, please scroll up and see what is missing in the form.