Name_______________________________________________________ Date_____________________________

Address (PO Box/Street)_________________________________________________________________________

City, State, Zip_________________________________________________________________________________

Phone #____________________________________ Cell #______________________________________________

E-mail address_________________________________________________________________________________

Age_______________ Date of Birth__________________________________________      

Emergency Contact Name______________________________________ Relationship_______________________

Phone numbers_________________________________________________________________________________

Do you have any medical or physical conditions that would affect your participation with ESS? Yes    No

If yes, please explain:____________________________________________________________________________

______________________________________________________________________________________________

Days and times that you are available to volunteer:____________________________________________________

Best way to reach you / best time to call if by phone:__________________________________________________

Please write a paragraph on the reverse side of this page explaining why you want to volunteer with ESS.

ALL: Sign attached liability forms and releases.  MINORS: Parent/guardian must sign consent form.

Use reverse side of page for explanations on any of the following:

HORSE EXPERIENCE (Circle all that apply):

None   some     novice    intermediate      advanced      breeder      trainer       other ________________

Own horse/s          Owned a horse             Have never been          Comfortable              Uncomfortable       

                                in the past                  around horses         around horses              around horses

Western      English     trail riding      jumping       4-H     Pony Club     basic handling       leading     grooming

Other (please specify and explain):_________________________________________________________________

______________________________________________________________________________________________

MY INTERESTS (Circle all that apply):

Today only                 weekly visits                     occasional/monthly visits   

Membership               future board member         supporter/donor   

Fundraising                outreach/public relations   

Horse trainer               horse handling                  horseback riding lessons         therapeutic programs

Horse grooming          horse care/feeding             cleaning stalls, grounds           fencing repairs      yard work

Other (please specify):___________________________________________________________________________