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Required fields are marked with an asterisk (*). 3 fields below (2 required) are a file upload/attachment, the size of all uploaded files must be less than 10MB.First name: *
Last name: *
Birthdate: *
A valid date as MM/DD/YYYY (for example: 11/30/2015)
Mailing address (street, city, state and zip code): *
Please list any specific skills or training you have that will best support your engagement with Special Equestrians. *
Please select the areas of interest in helping as a volunteer with our program. *
Please indicate days and time frames that you are available to volunteer. Typical volunteer shifts are 8:30 AM-12:00 PM or 3:00 PM-7:30 PM. *
Do you consent and authorize the use and reproduction by Special Equestrians, Inc. of any and all photographs and audio-visual materials for promotional printed/wed purposes, teaching seminars, and exhibition display? *
A Pennsylvania Criminal History Check is required for all volunteers of all ages. The Criminal History Check must be dated within 5 years of application date. To process online, please visit https://epatch.pa.gov
Once completed, please upload under the next item.
*Upload Background Check Here:
The total size of any/all file uploads must be less than 10MB
A Pennsylvania Child Abuse Clearance is required for all volunteers of all ages. The Child Abuse Clearance must be dated within 5 years of application date. To process online, visit https://www.compass.state.pa.us/cwis/public/home
Once completed. please upload under the next item.
*Upload Child Abuse Clearance here:
The total size of any/all file uploads must be less than 10MB
Have you lived outside the state of PA within the last 10 year? *
Volunteers over the age of 18 that have lived outside of PA within the last 10 years are required to complete an FBI Criminal Check (Fingerprinting). To schedule a fingerprinting appointment, please visit https://uenroll.identogo.com and enter service code 1KG6ZJ
Upload your receipt of completed fingerprints AFTER your appointment or your final results below.
Upload FBI Criminal Check (Fingerprints) if required here:
The total size of any/all file uploads must be less than 10MB
DISCLOSURE STATEMENT APPLICATION FOR VOLUNTEERS Required by the Child Protective Service Law
23 Pa. C.S. Section 6344.2 (relating to volunteers having contact with children)
I swear/affirm that I am seeking a volunteer position and AM NOT required to obtain a clearance through the Federal Bureau of Investigation, as:
• the position I am applying for is unpaid; and
• I have been a resident of Pennsylvania during the entirety of the previous ten-year period.
I swear/affirm that I have not been named as a perpetrator of a founded report of child abuse within the past five (5) years as defined by the Child Protective Services Law.
I swear/affirm that I have not been convicted of any of the following crimes under Title 18 of the Pennsylvania consolidated statues or of offenses similar in nature to those crimes under the laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of this Commonwealth.
Chapter 25
Section 2702 Section 2709 Section 2901 Section 2902 Section 3121 Section 3122.1 Section 3123 Section 3124.1 Section 3125 Section 3126 Section 3127 Section 4302 Section 4303 Section 4304 Section 4305 Section 5902(b) Section 5903(c) (d) Section 6301 Section 6312
(relating to criminal homicide) (relating to aggravated assault) (relating to stalking)
(relating to kidnapping) (relating to unlawful restraint) (relating to rape)
(relating to statutory sexual assault)
(relating to involuntary deviate sexual intercourse)
(relating to sexual assault)
(relating to aggravated indecent assault)
(relating to indecent assault)
(relating to indecent exposure)
(relating to incest)
(relating to concealing death of child)
(relating to endangering welfare of children)
(relating to dealing in infant children)
(relating to prostitution and related offenses)
(relating to obscene and other sexual material and performances) (relating to corruption of minors)
(relating to sexual abuse of children), or an equivalent crime under Federal law or the law of another state.
I have not been convicted of a felony offense under Act 64-1972 (relating to the controlled substance, drug device and cosmetic act) committed within the past five years.
I understand that I shall not be approved for service if I am named as a perpetrator of a founded report of child abuse within the past five (5) years or have been convicted of any of the crimes listed above or of offenses similar in nature to those crimes under the laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of this Commonwealth.
I understand that if I am arrested for or convicted of an offense that would constitute grounds for denying participation in a program, activity or service under the Child Protective Services Law as listed above, or am named as perpetrator in a founded or indicated report, I must provide the administrator or designee with written notice not later than 72 hours after the arrest, conviction or notification that I have been listed as a perpetrator in the Statewide database.
I understand that if the person responsible for employment decisions or the administrator of a program, activity or service has a reasonable belief that I was arrested or convicted for an offense that would constitute grounds for denying participation in a program, activity or service under the Child Protective Services Law, or was named as perpetrator in a founded or indicated report, or I have provided notice as required under this section, the person responsible for employment decisions or administrator of a program, activity or service shall immediately require me to submit current clearances obtained through the Department of Human Services, the Pennsylvania State Police, and the Federal Bureau of Investigation, as appropriate. The cost of clearances shall be borne by the employing entity or program, activity or service.
I understand that if I willfully fail to disclose information required above, I commit a misdemeanor of the third degree and shall be subject to discipline up to and including denial of a volunteer position.
I understand that the person responsible for employment decisions or the administrator of a program, activity or service is required to maintain a copy of my clearances.
I hereby swear/affirm that the information as set forth above is true and correct. I understand that false swearing is a misdemeanor pursuant to Section 4903 of the Crimes Code.
I hereby swear/affirm that the information as set forth above is true and correct. I understand that false swearing is a misdemeanor pursuant to Section 4903 of the Crimes Code *
Please provide a name and phone number for your emergency contact? *
Disclaimer
Release & Hold Harmless Agreement. You assume the risk of equine activities pursuant to Pennsylvania Law. The program at SPECIAL EQUESTRIANS, provides therapeutic riding and hippotherapy for children and adults with disabilities. Volunteers and horses are carefully selected and trained and safety equipment is required for all clients/riders since horseback is a risk exercise.
No participant will be accepted for riding services and no volunteer accepted for service until this form has been READ, UNDERSTOOD, COMPLETED AND SIGNED by the parent(s) or guardian(S) of a minor, or if the participant or volunteer is of legal age and sound mind, by the participant or volunteer.
Although participation in the program is under strict supervision and every effort is made to avoid injury or accident, the undersigned acknowledges the inherent risks involved in riding and working around horses. This includes bodily injury from horseback riding or being in close proximity to horses. Among other risks, both horse and rider can be injured in normal use or in competition and schooling.
I acknowledge the risks and potential for injury that may occur with the activities of horseback riding and working around horses, and I have discussed these risks with my child/and his/her/my physician. However, I feel that the possible benefits to myself/son/daughter/ward are greater than the risk assumed. Therefore agree to be legally bound for myself (or for my son/daughter/ward) heirs, executors or administrators and do hereby agree to release, hold harmless and indemnify SPECIAL EQUESTRIANS, its Board of Directors, Instructors, Therapists, Aides, Volunteers, Employees and the Township of Warrington, its Employees, Supervisors and Associates harmless of any claim for loss, injury or damages of every kind and nature whatsoever while at the SPECIAL EQUESTRIANS facility located on 2800 Street Rd. in Warrington, PA 18976 or while off the property in conjunction with a SPECIAL EQUESTRIANS, event or show.
Confidentiality Agreement
Special Equestrians shall preserve and respect the right of confidentiality for all individuals in our therapeutic riding and driving program. The volunteers and staff of Special Equestrians must keep confidential any and all medical, social, referral, personal, and financial information regarding individuals and their families in our program. The Executive Director of the program will address any breach of confidentiality. I understand and agree to abide by the confidentiality policy of Special Equestrians.
Release & Hold Harmless Agreement. You assume the risk of equine activities pursuant to Pennsylvania Law. The program at SPECIAL EQUESTRIANS, provides therapeutic riding and hippotherapy for children and adults with disabilities. Volunteers and horses are carefully selected and trained and safety equipment is required for all clients/riders since horseback is a risk exercise.
No participant will be accepted for riding services and no volunteer accepted for service until this form has been READ, UNDERSTOOD, COMPLETED AND SIGNED by the parent(s) or guardian(S) of a minor, or if the participant or volunteer is of legal age and sound mind, by the participant or volunteer.
Although participation in the program is under strict supervision and every effort is made to avoid injury or accident, the undersigned acknowledges the inherent risks involved in riding and working around horses. This includes bodily injury from horseback riding or being in close proximity to horses. Among other risks, both horse and rider can be injured in normal use or in competition and schooling.
I acknowledge the risks and potential for injury that may occur with the activities of horseback riding and working around horses, and I have discussed these risks with my child/and his/her/my physician. However, I feel that the possible benefits to myself/son/daughter/ward are greater than the risk assumed. Therefore agree to be legally bound for myself (or for my son/daughter/ward) heirs, executors or administrators and do hereby agree to release, hold harmless and indemnify SPECIAL EQUESTRIANS, its Board of Directors, Instructors, Therapists, Aides, Volunteers, Employees and the Township of Warrington, its Employees, Supervisors and Associates harmless of any claim for loss, injury or damages of every kind and nature whatsoever while at the SPECIAL EQUESTRIANS facility located on 2800 Street Rd. in Warrington, PA 18976 or while off the property in conjunction with a SPECIAL EQUESTRIANS, event or show.
Confidentiality Agreement
Special Equestrians shall preserve and respect the right of confidentiality for all individuals in our therapeutic riding and driving program. The volunteers and staff of Special Equestrians must keep confidential any and all medical, social, referral, personal, and financial information regarding individuals and their families in our program. The Executive Director of the program will address any breach of confidentiality. I understand and agree to abide by the confidentiality policy of Special Equestrians.
Check here to show you accept the terms stated above for yourself or for a minor volunteer for which you are the parental guardian.
