STAT®️ Ligonier Therapeutic Center - Volunteer Form

STAT®️ provides equine assisted learning, mental health, and physical health programming to adults and children.

Hippotherapy (Physical Therapy, Occupational Therapy, Speech-Language Pathology), Equine Assisted Learning (EAL), Equine Assisted Psychotherapy (EAP), EA-EMDR (Equilateral™), and Adaptive lessons.

STAT Welcomes You

Welcome to STAT®️! Volunteers are at the heart of what we do and who we serve

You have come to the right place if you enjoy helping others or are searching for some way to make a difference.

What is STAT®️ Inc?

STAT®️ provides a broad range of equine assisted services for adults and adolescents to include Physical Therapy, Occupational and Speech-Language Therapy on horseback, adaptive riding lessons, Horsepowered Reading/Math, and Equine-Assisted Learning (EAL) to include EAGALA (Equine Assisted Growth and Learning Association) and the O.K. Corral Series modalities.

Roxie

STAT®️'s Safety Policy

By checking this box you attest and acknowledge that you 1) do NOT have a history of any felony or misdemeanor conviction(s). 2) Acknowledge STAT®️'s Safety Policy of all clients and horses and you attest that the applicant does not have a history of any of the following: violence offences, sexual offences, animal cruelty and arson. (If you check this box, volunteering at STAT®️ is not appropriate and do NOT complete this form)

Your Contact Information:

Please fill in all the information below, attach (upload) required clearances (Child Abuse Clearance and PA State Police Background Check) at the end of this Application.

Volunteers are required to be 18 years or older. (Proof of age will be required if you are under 21).

First Name

Last Name

Phone Number

Email address

Date of Birth

Age

Home Address

Street

with apt number if applicable

City

State

Zip Code

What is your availability?

Monday Morning/Afternoon Mondays After 5 Wednesday Morning/Afternoon Wednesdays After 5 Other

If you have any experience with equines, please describe below.

Health History

Please list any restrictions (i.e., weight lift restriction, movement restrictions), allergies or condition that may affect you during the time at which you are volunteering (easily fatigued, asthma, allergic to bee stings, or any surgeries or conditions that STAT team members would need to be notified of for safety of clients, horses, or in the event of an emergency)

Authorization for Emergency Medical Treatment In the event emergency medical aid/treatment is required due to illness or injury to yourself while being on the properties leased by STAT Inc., I authorize STAT team members, therapists, volunteers, etc., to secure and retain medical treatment and transportation if needed and to release consent to do so (i.e., call 911)

Yes. I authorize STAT to retain emergency medical treatment in an event as necessary

Emergency Contact (Name and Phone Number)

2+ Year Professional Reference

Please write the full name and phone number or email of a professional reference and your relationship to this individual. (i.e., employer, supervisor, mentor, teacher, etc.) and how long you've known them. In writing in this individual's name and contact information, you are giving STAT permission to contact this person, to ensure compliance with STAT privacy and confidentiality practices and policies.

5+ Year Non-Family Personal Reference

Please write the full name and phone number or email of one unrelated personal reference and your relationship to this individual. (i.e., neighbor, know from volunteering elsewhere, etc.) and how long you've known them. In writing in this individual's name and contact information, you are giving STAT permission to contact this person, to ensure compliance with STAT privacy and confidentiality practices and policies.

Confidentiality Agreement I understand that all information, knowledge, or other (written and verbal) about participants at STAT is CONFIDENTIAL and WILL NOT BE SHARED WITH ANYONE without explicit written consent of the participant and their parent/guardian if the participant is a minor. This includes all medical, social, referral, personal, financial, including any/all photographic (photos, videos, media, etc.)and otherwise sensitive information. I (the undersigned) understand that individuals who breach confidentiality will be removed immediately from the STAT program(s).

I (undersigned) understand and attest to the Confidentiality Agreement as above written

Background Information Consent Have you ever been charged with or convicted of a crime (including misdemeanor, felony, or other)

Yes

If yes, Please explain in comment block below

Other Comments or Concerns

By checking this box you attest you are an adult who is at least 18 years of age. This form is not monitored 24/7 and is NOT for an emergency or in crisis. Call 988 or go to your nearest emergency room.

**Consent to Obtain Criminal Information from Volunteer Applicant** This Consent to Obtain Criminal Information ("Consent") is executed by Applicant, residing at Applicant's Address (above), hereinafter referred to as "Applicant," in favor of STAT Inc., a 501c3 public charity, located at 24 Stom Rd and 22 Horsepower Miracles Lane, both in Ligonier, PA 15658, hereinafter referred to as "Organization."

Purpose: The purpose of this Consent is to authorize the Organization to obtain and verify criminal information related to the Applicant as part of its volunteer applicant screening process.

Authorization: The Applicant hereby consents to and authorizes the Organization to request, obtain, and use any information regarding the Applicant's criminal record, including but not limited to information from local, state, and federal agencies. This information may include: - Criminal background checks - Arrest records - Convictions or other relevant criminal history information

Use of Information: The information obtained will be used by the Organization solely for the purpose of evaluating the Applicant's suitability for volunteer work and to ensure the safety and security of those who work for the Organization, those who the Organization serves, the property owner, as well as the animals that reside on the properties.

The Organization agrees to maintain the confidentiality of any criminal information obtained and will not use it for any other purpose. However, decisions can be made based on information included in criminal background checks and criminal history; i.e., an Applicant with any level of abuse to humans or animals will not be appropriate for a team member role of any level.

Release of Liability: The Applicant releases the Organization, its agents, employees, and representatives from any and all liability, claims, or demands that may arise from the acquisition, use, or release of criminal information obtained pursuant to this Consent, provided such use is in accordance with applicable laws and regulations.

Duration: This Consent shall remain in effect until the Organization completes its volunteer screening process or until the Applicant revokes it in writing, whichever comes first. Revocation of this Consent does not affect the information obtained prior to revocation.

Acknowledgment:

The Applicant acknowledges that they have read and understood this Consent and voluntarily agree to its terms. The Applicant understands that refusal to provide consent and/or content of the gathered information may affect their eligibility to volunteer with the Organization.

By checking this box you attest that ALL information you provided is accurate and you consent to all terms listed in this document.

Please upload required documents here (Child Abuse Clearance, PA State Police Background Check, Proof of Age if necessary)

Add file

Please upload a file

Thank You

This contact form is received by designated STAT®️ staff member(s) and your responses remain confidential. We are a small staff and we will do our best get back to you within 3 to 5 business days.

If you have questions, please contact our CEO, Catherine Markosky at 833-328-8728 or email: cmarkosky@statinc.hush.com

By submitting this form you give permission for STAT®️ staff to call/email you to briefly discuss the information on the form and explore service offerings. Submission of this form does not constitute a relationship with STAT®️, STAT®️ Staff, etc., and is inquiry only.

Your information will be encrypted.

STAT®️ Ligonier Therapeutic Center - Volunteer Form

STAT®️ provides equine assisted learning, mental health, and physical health programming to adults and children.

Welcome to STAT®️! Volunteers are at the heart of what we do and who we serve

What is STAT®️ Inc?

STAT®️'s Safety Policy

Your Contact Information:

STAT®️ provides equine assisted learning, mental health, and physical health programming to adults and children.

STAT® Inc.

Healing With Horsepower since 2007. Developers of the EQuine Affec(SM):