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Equine-Assisted Learning Activity
Healing Reigns, PLLC, ADULT
Registration
Client-Participant:_____________________Date
of Birth:________Age:_________________
Address:______________________________________________________________________
City/State:_________________________________________Zip
Code:___________________
Home Phone:_____________Cell Phone:________________ Work
Phone:________________
Emergency#:_____________________Parents/Legal Guardian Name(s):_________________
School Attending:_____________________Grade:______ Contact
Person:________________
Consent and Waiver of Liability:
I,(participant) _______________________________, for and in
consideration of the agreement of Healing Reigns to participate in Healing
Reigns Animal Assisted Activities/Animal Assisted activities, do hereby
forever release, acquit, discharge and hold harmless Healing Reigns PLLC.,
its owners, trustees, agents, employees, representatives, successors and
assigns, for all manner of claims, demands, and damages of every kind and
nature whatsoever, which the undersigned may now or in the future, have
against Healing Reigns PLLC, its owners, trustees, agents, employees,
representatives, successors or assigns on account of any personal
injuries, physical or mental condition, known or unknown, to the
undersigned and the treatment therefore as a result of, or in any way
growing out of, acts of Healing Reigns PLLC., its owners, trustees,
agents, employees, representatives successors or assigns, including but
not limited to, their negligence or gross negligence, in rendering
services above described or in any way incidental thereto.
Under
Arizona Law, AN EQUINE ACTIVITY SPONSOR IS NOT LIABLE FOR AN INJURY TO, OR
THE DEATH OF, A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE
INHERENT RISKS OF EQUINE ACTIVITIES THAT ARE OBVIOUS AND NECESSARY.
CITATION AZ ST S 12-553
Signature of
Participant:_______________________________________Date:_________________
Photo & Media Release
I consent to and authorize the use and reproduction by Healing Reigns PLLC
of
any and all photographs and any other audio-visual materials taken of
myself or my minor
child/guardian child for promotional materials, educational activities,
website or
for any other use for the benefit of the program.
___________________________________________________________
Signature of Participant
Date
Print Name_________________________________________________
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