Heritage Christian Stables Volunteers | Heritage Christian Services

Have you volunteered at Heritage Christian Stables before?*

Yes, I am a returning volunteer
No, I am a new volunteer

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Additional Phone

Email*

Date of Birth*

Best way to contact you*

Call
Text
Email

Employer / School

Are you under 18 years old or do you have a legal guardian?*

Yes
No

Parent / Legal Guardian Name*

First Last

Parent / Legal Guardian Address*

Street Address Address Line 2 City State ZIP Code

How did you learn about Heritage Christian Stables?

Do you have previous volunteer experience with therapeutic riding?

Yes
No

If yes, please explain.

Do you have previous horse experience?

Yes
No

If yes, please explain.

Do you have previous experience working with people with disabilities?

Yes
No

If yes, please explain.

Can you walk for an hour and jog for short distances?

Yes
No

If no, please explain.

Have you ever been charged with or convicted of a crime?*

Yes
No

If yes, please explain.*

Please indicate three references, other than relatives, who can vouch for your character.

Reference 1 Name*

First Last

Reference 1 Phone*

Reference 1 Address*

Street Address Address Line 2 City State ZIP Code

Reference 1 Email*

Reference 2 Name*

First Last

Reference 2 Phone*

Reference 2 Address*

Street Address Address Line 2 City State ZIP Code

Reference 2 Email*

Reference 3 Name*

First Last

Reference 3 Phone*

Reference 3 Address*

Street Address Address Line 2 City State ZIP Code

Reference 3 Email*

Emergency Information

Emergency Contact Name*

First Last

Emergency Contact Phone*

Relation*

Health Information

Health Insurance Company*

Health Insurance Policy #*

Allergies to Medications*

Current Medications

Emergency Treatment Statement*

In the event that emergency medical aid/treatment is required due to illness or injury during center activities, or while on the property of the agency, I authorize Heritage Christian Services / Stables to:
1. Secure and maintain medical treatment and transportation if needed.
2. Release participant records upon request to the authorized individual or agency involved in the medical emergency treatment.

*This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed "life saving" by the physician. This provision will only be invoked if the person(s) above is unable to be reached.

I agree to the emergency treatment statement.

Release and Hold Harmless Agreement*

As a volunteer at Heritage Christian Services / Stables, I can acknowledge the risks and potential for risks of a horseback riding program. However, I feel that the possible benefits to myself and the clients I worked with are greater than the risks assumed. I, hereby, intend to be legally bound for damages against Heritage Christian Services, Inc., its Board of Directors, instructors, therapists, volunteers and/or employees for any and all injuries and/or loss I may sustain while participating in Heritage Christian Services / Stables.

I agree to the the volunteer liability release.

Photo Release*

By selecting, I do consent, I authorize the use and reproduction by Heritage Christian Services, Heritage Christian Stables, and its representatives, of any and all photographs and any other audiovisual materials taken of me/my child for promotional material, educational activities, exhibitions or for any other use for the benefit of Heritage Christian Stables and Heritage Christian Services, including use on the Heritage Christian Stables' Facebook page. I understand that I may revoke this authorization at any time by a signed, dated notice to Heritage Christian Stables. I further understand that any such revocation does not apply to the extent that persons authorized to use my information may have already acted in reliance on this authorization.

I do consent to having my photograph used.
I do NOT consent to having my photograph used.

Confidentiality Agreement*

I understand the confidential nature of all records maintained by Heritage Christian Stables and I agree not to disclose or divulge any information contained in these records.

I agree to the privacy policy.

Volunteer Education Documentation*

Learning about Incidents and Abuse
-I have reviewed the information from the NYS Office for People with Developmental Disabilities (OPWDD) on Promoting Positive Relationships, Creating a Positive and Safe Environment, and Incident Reporting and Abuse. I know I am to contact my direct supervisor as soon as possible in the event of abuse. I can also call the NYS Justice Center for the Protection of People with Special Needs at 1-855-373-2122.

Code of Conduct
-I pledge to prevent abuse, neglect, or harm toward any person with special needs. If I learn of, or witness, any incident of abuse, neglect or harm toward any person with special needs, I will offer immediate assistance and then notify emergency personnel, including 9-1-1 where appropriate, and inform the management of this organization. I pledge also to report the incident to the Justice Center for the Protection of People with Special Needs.
I acknowledge that I have read and that I understand the Code of Conduct. I agree to abide by this Code of Conduct.

Compliance Education
-Heritage Christian Services Mission statement:
To provide a living and working environment that reflects the love of Christ in action; support and respect for each individual’s gifts, strengths and needs; opportunity to mature, to learn and to grow; a life of dignity, worth and expression to which all are entitled as God’s created children.
Heritage Christian Services is committed to honesty, integrity, and truth in intentions, actions and words. These are natural outcomes from living out the mission statement. Heritage Christian Services’ reputation is dependent upon the good judgment, ethical standards and personal integrity of every individual in our agency. As our agency continues to grow, it is of great importance that we always conduct our day-to-day activities in an ethical and responsible manner. We hold our employees, directors, volunteers and vendors to these standards.
How to do this:
o Avoid conflicts of interest or the appearance of them, disclose of potential or actual conflict to your supervisor or manager.
o Contact your supervisor or manager before soliciting money, favors or gifts as a representative of the agency to get permission.
o Decisions made must be in the best interest of the people we support and the organization. Employees, directors, volunteers should not profit from business decisions.
o Keep information confidential, such as names of people that receive services from Heritage Christian.

What is HIPPA?
-HIPPA is the federal Health Insurance Portability and Accountability Act of 1996. One of the primary goals of the law is to protect the confidentiality and security of healthcare information. HIPPA includes information that is created, received, used, or maintained by the agency. It requires safeguards to ensure the confidentiality, integrity, and security of electronic protected health information “PHI and/or EPHI.”
Examples of HIPPA violations:
o Posting personal information and/or pictures of individuals on social media sites, i.e. Facebook, Instagram, etc.
o Sharing/discussing private information about an individual with another party that is not privy to that information.
How you can protect PHI/EPHI:
o Ask your supervisor or manager before posting or sharing
o Ask if the individual has given written consent
It is every employee and volunteer’s responsibility to report a HIPPA violation. Violations need to be reported to the Compliance Officer and Privacy Officer, which can be done anonymously.
 Report any issues, concerns or possible violations to your manager or supervisor ASAP or call (585) 340-5797.

Laws – The False Claims Act and New York State Social Services Law
-This is a federal law that imposes liability on person(s) and/or companies who defraud governmental programs. The Act establishes liability when any person or entity improperly receives from or avoids payment to the Federal Government.
Examples include:
o Billing for a service that was not provided
o Documentation is false or inaccurate (for staff only, volunteers do not provide documentation for services). Staff can only document for services that they themselves provided
o Service is provided by unqualified staff

There are required elements of a Compliance Plan which include:
1. Witten Policies and Procedures
2. Compliance Program Oversight
3. Training and Education
4. Effective, Confidential Communications
5. Enforcement of Compliance Standards
6. Auditing and Monitoring
7. Responding to Offenses & Developing Corrective Plans
8. Whistleblower Provisions & Protections

Why do we need a Compliance Plan and why do volunteers need to review it annually? It helps to:
o Identify weakness and make changes as needed
o Strengthen practices
o Promotes the agency’s commitment to provide quality services, regulatory compliance and ethical conduct
o Education
o Drive more efficient and effective operations
Innocent mistakes happen and occasionally there are errors with documentation. If it is determined we billed Medicaid more than we should, the agency must return the money. Your responsibilities as a volunteer are to:
o Review the Corporate Compliance Plan, including HIPPA and Laws, once every year
o Comply with the laws, regulations, policies, procedures and practices
o Report any issues, concerns or possible violations to your manager or supervisor ASAP or call (585) 340-5797.

I have reviewed the included materials for the Volunteer Education Documentation Information.

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Heritage Christian Stables Volunteer Form

Please indicate three references, other than relatives, who can vouch for your character.

Emergency Information

Health Information