Therapeutic Riding Class Registration & Release Form Note: If you have difficulty with the date fields, try entering the dates in YYYY-MM-DD format. Name (required) Date of Birth Age Height Weight Disability Address (Street) Address (City) Address (State) Address (Zip) Parent / Guardian Relationship Parent / Guardian Address (Street) Parent / Guardian Address (City) Parent / Guardian Address (State) Parent / Guardian Address (Zip) Phone (Home) Phone (Work) Phone (Cell) Email (required) Preferred method of contact: Home PhoneWork PhoneCell PhoneEmail May we email you? Check the items you'd like to receive NewslettersProgram informationSurveysVolunteer opportunitiesFundraising events How did you hear about us? FriendRelativeNewspaperFlyerOther (describe below) If other, please explain Emergency Contact 1 - Name Emergency Contact 1 - Relationship Emergency Contact 1 - Phone (Home) Emergency Contact 1 - Phone (Cell) Emergency Contact 2 - Name Emergency Contact 2 - Relationship Emergency Contact 2 - Phone (Home) Emergency Contact 2 - Phone (Cell) 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. The undersigned acknowledges that he / she has read this Registration and Release form in its entirety ; that he / she understands the terms of this release and has signed this release voluntarily and with full knowledge of the effects thereof. Participant's Signature Date Parent or Guardian's Signature (required if participant under 18) Date 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. Participant's Signature Date Parent or Guardian's Signature (required if particpant under 18) Date 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) Physician's Name Physician's Phone Physician's Address (Street) Physician's Address (City) Physician's Address (State) Physician's Address (Zip) Preferred Medical Facility Health Insurance Carrier Policy Number Please indicate any allergies Please indicate any disability, limitations, or medications or medical conditions that may affect the participant, which Victoria Acres should be aware of 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. Consent Signature Date Parent or Guardian's Signature (required if participant is under 18) Date 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. Please describe disability Please share any medical concerns that we should be aware of, i.e. allergies, history of seizures, etc. How is your posture, balance, and movement / coordination ? Do you have any balance problems ? Describe general attitude and behavior Communication challenges and methods used (verbal, sign, PEC, etc.) Please tell us of your experience with horses If you have a goal or goals that you would like to reach during your enrollment within our program, please share. Describe areas of interest, games and activities enjoyed 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.