As part of our agency standards and PATH (Professional Association of Therapeutic Horsemanship) accreditation we require that all riders, staff and volunteers review and update their contact information and forms. These forms need to be updated annually and are mandatory in order for the program to remain in compliance. Please read through all of the sections and feel free to contact me if you have any questions or would like a printed copy. Once you have read through please make sure to click the "I agree" section before submitting your paperwork.

Volunteer Name and Contact Information:

Please opt-in to our new text messaging system! You can do this by selecting the "Email w/ Text Notification" option below. This will allow for easier and quicker updates!


Emergency Contact Information:


Abuser Registry Annual Notice:


The Ohio Department of Developmental Disabilities (“Department”) maintains an Abuser Registry which is a list of employees who the Department has determined have committed one of the Registry offenses listed below. If your name is placed on the Registry you are barred from employment as a Developmental Disabilities employee in the state of Ohio. Because other state agencies require employers to check the Abuser Registry, placement on the Registry also prohibits you from being employed (1) by a Medicaid agency, being an owner (5 percent or more) of an agency or having a Medicaid Provider Agreement as a non-agency provider; (2) in a position to provide Ombudsman services or direct care services to anyone enrolled in a program administered by the Ohio Department of Aging; and (3) by a home health agency in a direct care position and may prevent you from being hired in a nursing home or residential care facility in a direct care position.

The name of any “Developmental Disabilities (DD) employee” may be placed on the Registry. DD employee includes any Department employee, any employee of a county board of DD, an independent provider under Ohio Revised Code section 5123.16, and any employee providing specialized services to an individual with developmental disabilities. A specialized service is a program or service designed to primarily serve individuals with developmental disabilities including services by an entity licensed or certified by the Department.

Abuser Registry Offenses:
• Physical Abuse - the use of any physical force that could reasonably be expected to result in physical harm.

• Sexual Abuse - unlawful sexual conduct (unprivileged intercourse or other sexual penetration) and unlawful sexual contact (unprivileged touching of another’s erogenous zone).

• Verbal Abuse - purposely using words to threaten, coerce, intimidate, harass or humiliate an individual.

• Prohibited Sexual Relations- Consensual touching of an erogenous zone for sexual gratification and the individual is in the employee’s care and the individual is not the employee’s spouse.

• Neglect - when there is a duty to do so, failing to provide an individual with any treatment, care, goods or services necessary to maintain the health or safety of the individual.

• Misappropriation (Theft) - obtaining the property of an individual or individuals, without consent, with a combined value of at least $100. Theft of the individual’s prescribed medication, check, credit card, ATM card and the like are also Registry offenses.

• Failure to Report Abuse, Neglect or Misappropriation - the employee unreasonably does not report abuse, neglect or misappropriation of the property of an individual with developmental disabilities, or the substantial risk to such an individual of abuse, neglect or misappropriation, when the employee should know that their non-reporting will result in a substantial risk of harm to such individual.

• Conviction or plea of guilty to: Offense of Violence - R. C. 2901.01, including convictions for the offense of Assault, Menacing, Domestic Violence or Attempting to commit any offense of violence; Sexual Offenses - R. C. Chapter 2907; Theft Offenses - R. C. Chapter 2913; Failing to provide for a functionally impaired person – R.C. 2903.16; Patient Abuse or Neglect - R.C. 2903.34; Patient Endangerment - 2903.341; and/or Endangering Children - 2919.22.

ORC 5123.542 requires an employer to provide annual written notification to each of its developmental disabilities employees explaining the conduct for which a developmental disabilities employee may be included in the registry established under section 5123.52 of the Revised Code.

More information is available on the Department’s website under the Health and Safety tab. The Registry website is at: https://its.prodapps.dodd.ohio.gov/ABR_Default.aspx.
Please call the Department at 614-995-3810 with any questions regarding the Registry.

DODD REV- 7.24.13
ACC 2.21


Covid-19 Informed Consent

Achievement Centers for Children - Camp Cheerful Covid-19 Informed Consent
I am aware of the risks of contracting or spreading Covid-19 while volunteering, or receiving in person services at the Achievement Centers for Children's Camp Cheerful location during the time of a public health pandemic and I am assuming those risks by choosing to participate.

I agree to and will follow all guidelines for personal hygiene, personal safety and public safety as required by The Achievement Centers for Children's recreation programs. I/the participant will only participate in the ACC service if I/the participant and all individuals living in the home are symptom free. These guidelines are specifically detailed in each programs re-opening procedures that I have reviewed. Everyone is required to do the following:
-Complete a health screening before arrival including taking temperature.
-I will not come to Camp Cheerful if I or an individual living in my home have a temperature of 100.4 or higher or if I have illness symptoms including cough, sneezing, chest congestion or shortness of breath, or additional signs of potential spread of any virus or bacteria/disease.
-I will cancel my services/volunteer commitment if I have been in contact with someone who has presented with illness symptoms. In the event I or someone in our household tests positive for COVID-19 or are exposed to someone who tested positive, I agree to notify the Program Manager who will work with the local Department of Health to help facilitate effective contact tracing/notifications to potentially exposed individuals and follow the disinfecting protocol for the facility.
-This may require you/the participant to temporarily discontinue on site services for 14 days.
-Hand wash/hand sanitize immediately upon arrival.
-Wear a face covering.
-I understand that some participants may not adhere to 100% compliance regarding wearing a face covering throughout their time participating in an ACC activity. This means that I/my participant may incur an additional risk of exposure due to inconsistent mask use. If I/my participant are inconsistent with wearing a mask, this may also cause additional personal risk for exposure. ACC staff will wear some form of face covering except when outside and maintaining acceptable social distancing.
-Complete a health screening upon arrival including taking of temperature.
-Maintain acceptable social distance of six feet or more.
-Encouraged to not touch your face, mouth or eyes.
-Hand wash/hand sanitize prior to leaving the facility.
-If onsite more than an hour or two hand wash and sanitize additional times as needed.

When you are not participating in an ACC service, you agree to take steps to minimize your/the participant’s exposure to Covid-19.
-If you have a job that routinely exposes you to other people who are infected, you will immediately let the ACC know so that appropriate precautions can be taken.
-Please follow current public health recommendations: avoid large gatherings, avoid poorly ventilated places, wear face masks, cover coughs and sneezes, wash hands often, practice social distancing, clean and disinfect, monitor your health daily, etc,. Failure to do so may require you/the participant to temporarily discontinue services for 14 days.
-Reference: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html

The above responsibilities may change if additional local, state or federal orders or guidelines are provided. ACC will notify you of any necessary changes when you make notification regarding your travel plans.
Our Commitment to Minimize Exposure
ACC has taken steps to reduce the risk of spreading Covid-19 within the buildings and grounds. We have posted our efforts on our website and some specific buildings. Our efforts at keeping you/your participants safe will be a dynamic process based on the current federal, state, and local health department guidelines. Please let ACC know if you have questions about these efforts.
The individual programs at Camp Cheerful will engage in regular cleaning and sanitizing of the facility on a daily basis and throughout the day as recommended by the Centers for Disease Control and Prevention for the safety of clients, employees, volunteers, visitors and the horses.

Confidentiality in the Case of Infection
If you/your participant or an individual living in the home has tested positive for Covid-19, ACC will work with you and notify the local public health authorities. Only the minimum personal information necessary for public health data collection and appropriate contact tracing will be released


Equine Waiver

Equine Activity Release, Waiver, and Assumption of Risk Agreement:
This Equine Activity Release, Waiver, and Assumption of Risk Agreement (“Equine Activity Agreement”) is given under the Ohio Equine Activity Liability Act, Ohio Revised Code Section 2305.321 (the “Act”). The undersigned, on his or her own behalf, and on behalf of any minor or developmentally disabled adult named below, and on behalf of their respective heirs, assigns, successors, executors, administrators, and legal representatives, does hereby release, acquit and discharge Achievement Centers for Children, and its officers, directors, employees, representatives, volunteers, servants, staff, agents, heirs, successors and assigns, including any “equine professional” as defined by the Act (“Achievement Centers”), from and against any and all claims, claims for relief, actions, causes of action, liabilities, injuries, damages, demands, rights, losses, costs, interest, expenses, including attorney fees, of any kind, description or nature whatsoever, whether arising out of contract, tort, statute or otherwise, in law or in equity, that arise from or relate in any manner to the participation in or presence at equine activities by Achievement Centers within the State of Ohio by the undersigned and by any minor or developmentally disabled adult participant named below (“Loss”). The undersigned agrees and acknowledges that this Equine Activity Agreement is applicable regardless of whether any Loss, injury or death results from the negligence of the Achievement Centers, or from any other cause and hereby warrants and represents that he or she is in fact the legal parent or guardian of any minor or developmentally disabled adult participant named below, with full rights of custody and control, has the authority to sign this Equine Activity Agreement on behalf of any such minor or developmentally disabled adult participant, and consents to any such minor’s or developmentally disabled adult’s presence and participation in equine activities at the Property.

The undersigned acknowledges that this Equine Activity Agreement is given on behalf of and is binding upon the undersigned, and also on behalf of and is binding upon any such minor or developmentally disabled adult participant named below and their respective heirs, executors, administrators, personal representatives, successors and assigns; and the undersigned agrees that this Equine Activity Agreement is fully binding on the undersigned as if it were entered into solely on his or her own behalf. The undersigned hereby acknowledges that he or she has full and complete notice and understanding of all the risks, known and unknown, inherent in equine activities, and that these risks cannot be eliminated, altered or controlled regardless of the care used, the skill or experience possessed, or the precautions taken (in each case if any), by anyone; that these risks may cause, contribute to, or result in the death, physical injury, psychological injury, emotional/mental injury, or disability of the undersigned and of any minor or developmentally disabled adult participant named below or damage to the participant’s property or financial loss otherwise (the “Risks”), including, but not limited to: (a) the propensity of an equine to behave in ways, including dangerous, unpredictable and potentially uncontrollable ways, that may result in injury, death, or loss to persons on or around the equine; (b) the unpredictability of an equine’s reaction to sounds, weather, environment, surroundings, sudden or other movement, familiar or unfamiliar objects, persons, or other animals; (c) hazards, including, but not limited to, surface or subsurface conditions including, for example, obstructed or uneven surfaces or conditions that could cause the participant or equine to trip or fall; (d) a collision or contact with another equine, another animal, a person, or an object; (e) misuse or failure of tack, gear and equipment; (f) the potential of an equine activity participant or other person(s) to act in a negligent manner or otherwise that may contribute to injury, death or loss to the person or property of the participant or to other persons, including, but not limited to, failing to maintain control over an equine; (g) exposure to mold, allergens, bacteria, toxins, viruses, disease; and (h) exposure to uncontrollable elements, such as, for example, heat, humidity, cold, wind, and rain.
The undersigned acknowledges that he or she is in the best position to understand and evaluate any added risk caused by any disability, limitation, illness, or condition of the undersigned or of any minor or developmentally disabled adult participant named below.

Although the undersigned is aware of the nature and extent of the Risks, he or she expressly accepts and assumes all risks of bodily injury, psychological injury, emotional/mental injury, disability, and/or death, and any property damage or other physical or financial loss that may occur as a result of the participation in equine activities by the undersigned or by any minor or developmentally disabled adult participant named below. This Equine Activity Agreement is given on specific consideration of the permission granted by the Achievement Centers to the undersigned, and to any minor or developmentally disabled adult participant named below, to participate in equine activities. The undersigned agrees to indemnify and save the Achievement Centers harmless from any and all judgments, damages, or expenses associated with any claims, demands, or lawsuits made against the Achievement Centers, by or on behalf of any person, that may arise as a result of the presence at or participation in equine activities by the undersigned, and by any minor or developmentally disabled adult participant named below. The undersigned, on his or her own behalf, and on behalf of any minor or developmentally disabled adult named below, authorize and consent to any first aid or emergency medical care which may be administered as deemed necessary or appropriate, due to injury or sickness caused by or incurred in the course of any equine activity. To the extent possible, this Equine Activity Agreement shall be construed in such manner as will render each provision fully enforceable; but if any provision of this Equine Activity Agreement shall be unenforceable, such provision (or so much thereof as is unenforceable) shall be deleted and the remainder of this Equine Activity Agreement shall continue in full force and effect. The undersigned states that he or she knowingly and voluntarily executed this Equine Activity Agreement and asserts that he or she understands all the terms used herein and the consequences thereof and acknowledges that this Equine Activity Agreement is binding upon the heirs, administrators, executors, representatives, successors and assigns of the undersigned and of any minor or adult with a developmental disability named below. This Equine Activity Agreement shall remain valid until released in writing by the undersigned.


Background Information

I understand and authorize Achievement Centers for Children to verify the information on my volunteer application. I release Achievement Centers for Children, its agents, and organizations supplying information from all liability and responsibility, damages and claims of any kind arising from this investigation of my background. I understand that misrepresentations or omissions may be cause for my immediate rejection as an applicant for a volunteer position with Achievement Centers for Children or my termination as a volunteer. I understand that I may be subject to fingerprinting and a criminal background check according to Ohio Revised Code Section 109.575 et seq. I hereby confirm, represent, and warrant that I have never been convicted of or charged with a violent crime, child abuse or neglect, child pornography, child abduction, kidnapping, rape or any sexual offense, nor have ever been ordered by a court to receive psychiatric or psychological treatment in connection with the crimes previously listed.


Volunteer Status

I understand on behalf of myself, or my child, that this is an application for and not a commitment or promise of a volunteer opportunity. I understand that information will be considered confidential to the fullest extent allowed by law. I, or my child, choose to perform my service out of my own, or my child’s own, free will, without promise, expectation, or receipt of remuneration. For the purposes of the volunteer activity/activities I participate in, I acknowledge and agree that I am not an employee or agent of Achievement Centers for Children for any purpose, and my volunteer services are neither controlled nor mandated by Achievement Centers for Children. If I am under the age of 18, I may only participate in volunteer service with the express written consent of my parent or guardian.


Equipment and Facility Inspection

If either myself, or my child, are in attendance at the volunteer activity, we will immediately advise Achievement Centers for Children of any unsafe condition that I, or my child observe. I, or my child, may refuse to participate in the volunteer activity until all unsafe conditions observed, by me, or my child, have been remedied.


Indemnification/Insurance

As part of the consideration tendered for myself, or my child, being permitted to participate in volunteer activities; I agree, on behalf of myself and my child to, and hereby do, waive any and all claims against, and do fully release and hold harmless, Achievement Centers for Children its officers, directors, employees, agents, volunteers, successors and assigns from any and all claims related to any illness, injury, including loss of life, property damage, or loss of any other description which I, or my child, may sustain arising out of, or in any way associated with my, or my child’s, participation in volunteer activities, including, but not limited to, all attorneys’ fees and disbursements through and including any appeal. I understand that during the term of my volunteer activities, Achievement Centers for Children does not provide workers compensation coverage, self-insurance or other health benefit plan(s), including but limited to, hospitalization, disability and/or life insurance because I am not a Achievement Centers for Children employee. I further understand that if my child is under age 10, that I will be present to supervise my child during the volunteer activity.


Consent to Treatment

In the event of injury or illness, I authorize, on behalf of myself and my child, Achievement Centers for Children to administer first aid, CPR or use an AED and/or obtain medical treatment at the nearest and most adequate facility of Achievement Centers for Children’ choice. I, and/or on behalf of my child, hereby release and forever discharge the Achievement Centers for Children from any claim whatsoever which arises or may hereafter arise on account of any medical assistance, first aid treatment or other medical services rendered in connection with an emergency that arises during my participation and/or the participation of my child in volunteer activities. I, and/or on behalf of my child, declare and represent that I, or my child, are in good mental and physical health and condition and have the skill level required for the volunteer activities, that I, or my child, do not have any medical condition that is adverse to participation in the volunteer activities and that I, or my child, are not under the influence of alcohol or drugs. If I, or my child, are currently taking medication, I declare that I have consulted a physician and have approval to participate in the volunteer activities while under the influence of the prescribed medication. I warrant that I will notify any personnel prior to the beginning of the volunteer activities of any medications or drugs I am, or my child(rens)(s) are currently taking, or any conditions that may complicate medical treatment, including, but not limited to, known allergic conditions.


Risk of Harm

I understand and agree on behalf of myself, or my child, that it is possible that I, or my child, may be injured or otherwise harmed during volunteer activities due to accidents, acts of nature, or my, or my child’s negligent or intentional acts, or the negligent or intentional acts of Achievement Centers for Children’ employees and/or volunteers or others. While Achievement Centers for Children has taken some steps to reduce the chance of injuries or harm to you, or your child, Achievement Centers for Children has no control over most risks, and, thus, cannot and does not guarantee or assume responsibility for my, or my child’s, safety, or my, or my child’s, property while I, or my child, are engaged in volunteer activities. I, on behalf of myself and my child, shall take full responsibility for myself, or my child, and assume the risk of harm or damage while volunteering at Achievement Centers for Children. I, or my child, shall also take all necessary and reasonable precautions and act in a manner that will help protect me, or my child, and my or my Child’s property.
I recognize and acknowledge that there are risks associated with volunteer activities, including but not limited to those related to:
Repetitive motion, exertion, ergonomics, slips, trips and falls, lifting, misuse or failure of equipment, struck by, struck against, compressed in, caught in between, entangled, rubbed, cut, punctured, abraded or jarred by vibration from equipment or materials, contact with guests or other staff members, and traffic-related risks.


Notice of Privacy Practices For Volunteers

Thank you for Volunteering! This notice describes how you, as a volunteer, are affected by the Health Insurance Portability and Accountability Act (HIPAA). Please review carefully and sign and date below.

HIPPA is a federal law that was passed in 1996. These laws protect a person’s health information from being shared with other people who DO NOT need to know it. As a volunteer of the Achievement Centers for Children (ACC) you are legally responsible to follow these same policies that protect the health information of all persons served at ACC.

Health information includes: Medical diagnosis of a person, types of services a person receives, how a person pays for their service, identifiable information of a preserved, such as their name, address, phone number.

When handling files at ACC, remember the information in the files is confidential and should not be shared. For example, you CANNOT tell anyone about that person’s personal information. You would be breaking the law if you shared with others what you saw in one of our files and this would also include sharing that this friend received services from us.

When sending a fax, make sure the ACC cover page goes with your fax’ specifying to whom the fax is going. The more specific the fax cover sheet, the better.

All ACC computers are password protected. This is for confidentiality. If you use an ACC computer in your volunteer work, NEVER share your password with anyone. If you leave your computer, make sure you are logged off from your computer.

When disposing of health information documents, use a shredder or shredder bin when disposing of these documents. Do not talk about or discuss an individual’s information out in the open, in common areas, such as the lunch room, restrooms, or in the hallways or lobby. If information needs to be shared, go to a private place like an office or conference room to have your conversation.

When can a person’s health information be shared and with whom? In most cases, you would not be faced with sharing health information. However, if someone does ask you for information about a person, you should check with your ACC volunteer supervisor to see if it is okay if any health information can be shared. Your ACC volunteer supervisor will make sure there is a signed authorization form that will allow you to share information. If there is not an authorization form, then you will not be able to share information.


Privacy Notice:
I have received a copy of the privacy notice from Achievement Centers for Children. I have read the Information and understand it or I will contact my ACC volunteer supervisor for clarification.
Do You Agree To All of the Above?
Thank you again for volunteering and if you understand and agree with all of the statements above please sign below by clicking "I Agree" below.