Name:
*
Email:
Home Phone:
Cell Phone:
Home Address:
City:
Zip Code:
Employer or School:
Date of Birth:
In Case of Emergency (ICE):
ICE Phone Number
Allergies:
Medications:
Why are you interested in volunteering with WarHorses for Heroes?
If yes, please explain:
I (printed below) authorize WarHorses for Heroes to receive
information from any law enforcement agency, including the police departments and sheriff’s departments, of this
state or any other state or federal government, to the extent permitted by state and federal law, pertaining to any
conviction I may have had for violations of state or federal criminal laws, including but not limited to convictions
for crimes committed upon children. I understand that such access is for the purpose of considering my application
as an employee/volunteer, and that I expressly DO NOT authorize the center, it’s affiliate center Oak View Stables,
any directors, officers, employees, or other volunteers to disseminate this information in any way to any other
individual, group, agency, organization or corporation.
Printed Name:
Signature:
Date:
If yes, enter license #:
State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
I understand that all information (written and verbal) about participants and volunteers at WarHorses for Heroes is
confidential and will not be shared with anyone without the expressed written consent of the participant and his/her
parent/guardian in the case of a minor.
Signature:
Date:
I understand that the information provided above is accurate to the best of my knowledge. I know of no reason why I
should not participate in this center’s program.
Signature:
Date:
Submit