Therapeutic Riding Class Registration & Release Form

    Note: If you have difficulty with the date fields, try entering the dates in YYYY-MM-DD format.

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    Photo and Publicity Release

    Please read each of the following items before choosing a selection below.

    (1) Victoria Acres Equine Facility, Inc. may use my (my child's) photograph or image in its print, online and video publications ;
    (2) Release Victoria Acres Equine Facility, Inc., its employees and any outside third parties from all liabilities or claims that I might assert in connection with the above - described activities ; and
    (3) I waive any right to inspect, approve or receive compensation for any materials or communications, including photographs, videotapes, DVD's, website images or written materials, incorporating photos / images of me (my child).

    I do authorizeI DO NOT authorize

    Liability Release

    I acknowledge the risks and potential for risks for horseback riding and related equine activities including grievous bodily harm. However, I feel that the possible benefits to myself are greater than the risks assumed. I hereby, intending to be legally bound for myself, my heirs and assigns executors or administrators, waive and release forever all claims for damages against Victoria Acres Equine Facility, Inc. its Board of Trustees, Instructors, Therapists, Aides, Volunteers and / or Employees for any and all injuries and / or losses I (my child) may sustain while participating at a Victoria Acres Equine Facility program from whatever cause including, but not limited to, the negligence of these related parties.

    Confidentiality Policy

    At Victoria Acres, we place great importance on protecting the confidential information of our clients, our staff and our volunteers. "Confidential information" includes, but is not limited to, personally identifiable information such as surnames, telephone numbers, addresses, emails, etc., as well as the non - public business records of Victoria Acres. In particular, medical information about clients and information about their disabilities or special needs, must be protected as confidential information. Participants and their parents / guardians shall never disclose confidential information to anyone about any participant in our program other than Victoria Acres' staff. Participants and their parents / guardians must seek staff permission before taking any pictures or videos.

    Authorization for Emergency Medical Treatment

    In the event emergency medical aid / treatment is required due to illness or injury while being on the property of the facility, I authorize Victoria Acres Equine Facility, Inc. to:

    1. Secure and retain medical treatment and transportation, if needed.
    2. Release records upon request to the authorized individual or agency involved in the medical emergency treatment.

    (See Emergency Contact Information Above)

    Consent Plan

    (to be invoked in the event that your emergency contact cannot be reached)

    I give consent for emergency medical treatment / aid (including X - rays, surgery, hospitalization, medication, and any treatment procedure deemed "life saving" by the physician) in the event of illness or injury while on the property of the facility.

    NOTE: If you choose non-consent for emergency medical treatment/aid in the vent of illness or injury while on the property of the facility, please request a Non-Consent Form, which will require notarization.

    General Information Form

    It is helpful for the staff at Victoria Acres to know your participation goals, interests and understand your current status prior to developing a program for you. Please complete the following questions.

    Participant's Medical History and Physician's Statement

    In addition to this form, a medical history for the participant must be filled out and signed by a physician.

    Medical History Form

    Please complete all required fields and check the boxes next to the release(s) before sending.