THE CARR CENTER
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special Riders Volunteer form
*
Indicates required field
Name
*
First
Last
Phone Number
*
Age (must be 14 years or older)
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Last four digits of your social security number (if 18 and over)
*
Email
*
Please check dates you are available
*
Monday, August 19
Monday, August 26
Monday, September 9
Monday, September 16
Monday, September 23
In case of an emergency, please contact:
Name
*
First
Last
Phone Number
*
In the event of an emergency, you give permission for medical care, such as contacting emergency squad. Further, The Carr Center will initiate efforts to contact your emergency contact.
Confidentiality Policy:
Information received concerning The Special Riders, their families and employees of The Carr Center is confidential and is not to be discussed with anyone outside of The Carr Center or the Special Riders Program. Any individual, contractor or agency that violates this policy will be held accountable and subject to disciplinary and/or legal action, which may include dismissal.
By signing, you agree to the Emergency Plan and Confidential Policy.
Signature
*
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