2023 Volunteer/Staff Annual Update Form Great Plains Adaptive Riding AcademyToday's Date(Required) MM slash DD slash YYYY Legal Name(Required) Gender Pronouns Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Birthdate DD slash MM slash YYYY In Case of emergency notify(Required) Phone(Required)Physician(Required) Phone(Required)Preferred Medical Facility(Required) Medical Conditions Requiring Attention(Required) Medications/Dosage/Allergies(Required) Insurance Carrier(Required) Policy Number(Required) Consent: In the event of an emergency, I consent to have Great Plains call 911 as needed. Signature of Volunteer or Parent/GuardianDate(Required) MM slash DD slash YYYY By signing below, you are formally renewing all previously provided information, agreements, releases, and consents unless otherwise specified above. This includes your photo release, confidentiality agreement, background information, liability release and medical treatment release. You are also confirming that you have reviewed and understood the volunteer training handbook available on the website.Volunteer Signature:Date(Required) MM slash DD slash YYYY Parent/Guardian Signature (if under 18):Date(Required) MM slash DD slash YYYY VOLUNTEER BACKGROUND SCREENING Great Plains Adaptive Riding Academy requires all volunteers age 18 and older to undergo a background screening conducted by Background Info USA. The screening cost is $12.00, to be paid by each volunteer. Once Great Plains Adaptive Riding Academy receives your signed Volunteer Application, Great Plains will provide the volunteer’s name and email address to Background Info USA. They will then email the volunteer directly to collect the information and consent for the background screening. Please respond to this email quickly so Great Plains can receive the screening results and you can begin your volunteering session. The form must be completed on a computer, not a tablet or phone. The screening includes a National Criminal Search and National Sex Offender Search. The results of the screening will be reported to the Great Plains Board of Directors.Consent(Required) I consent to have a background screening performed and the results reported to Great Plains Adaptive Riding Academy. I DO NOT consent to have a background screening performed and the results reported to Great Plains Adaptive Riding Academy and I understand this disqualifies me from volunteering. I am under 18 years of age. Signature (Parent/Guardian if under 18)Date(Required) MM slash DD slash YYYY Volunteer Name(Required) Email address for Background Info USA to send form(Required) Assumption of Risk of Domestic Animal Activity WarningName of Participant Under Kansas law, there is no liability for an injury to or the death of a participant in domestic animal activities resulting from the inherent risks of domestic animal activities, pursuant to K.S.A. 60-4001 through 60-4004. You are assuming the risk of participating in this domestic activity. Inherent risks of domestic animal activities include, but shall not be limited to: The propensity of a domestic animal to behave in ways, i.e., running, bucking, biting, kicking, shying, rearing, falling or stepping on, that may result in an injury, harm or death to a person on or around them; The unpredictability of a domestic animal’s reaction to such things such as sounds, sudden movement and unfamiliar objects, persons or other animals; Certain hazards such as surface and subsurface conditions; Collisions with other domestic animals or objections; and The potential of a participant to act in a negligent manner that may contribute to injury to the participant or others, such as failing to maintain control over the domestic animal or not acting within such participant’s ability. “Participant” means any person who engages in a domestic animal activity. I acknowledge the potential for risk of horseback riding and working with horses. However, I feel that the possible benefits for myself, son, daughter, and/or ward are greater than the risk assumed. I hereby, intending to be legally bound, for myself legally heirs and their assigns, executors or administrators, waive and forever release all claims for damages or otherwise against Great Plains Adaptive Riding Academy, its Board of Directors, Officers, Instructors, Therapists, Aides, Volunteers and or employees, any and all injuries and/or losses I/my son/my daughter/my ward may sustain while participating at Great Plains Adaptive Riding Academy. Yes, I would like the above person named to participate in an equestrian program at Great Plains Adaptive Riding Academy. All activities will be under supervision, and reasonable effort will be made to avoid any accident, Great Plains Adaptive Riding Academy will have no Liability in the event an accident may occur. Volunteer Signature:Rider, Volunteer, Parent/Guardian/StaffDate(Required) MM slash DD slash YYYY
