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Equine-Assisted Learning Activity
PARTICIPANT
registration, RELEASE, AND ACKNOWLEDGEMENT OF RISK form
Registration and release
Client-Participant:_______________________________ Date of Birth:
_____________Age:_________________
Address:________________________________________________________________________________
City/State:____________________________________________________ Zip
Code:__________________
Home Phone: __________________Cell Phone:________________ Work
Phone:____________________
Emergency#:_____________________Parents/Legal Guardian Name(s):____________________________
Home Phone:________________ Cell Phone:________________ Work
Phone:______________________
School Attending:_____________________Grade:_________ Contact
Person:_______________________
Court Involvement: _____________________________On Probation
for:____________________________
Other Agencies involved with
client:_________________________________________________________________
Consent and Waiver of Liability:
I hereby request that the client/participant named above be
accepted into the equine-assisted mental health/learning program operated
by Meloney Nunez, M.Ed., M.A., Licensed Professional Counselor and Healing
Reigns. I acknowledge that Meloney Nunez or a Healing Reigns
representative has fully explained to me the scope of the equine assisted
mental health/learning program including the potential for injury which
can occur from riding horses, caring for horses or being involved in
therapeutic/learning activities that include horses. Because of the
potential benefits of the EAP program, I hereby waive any claim which I or
the client may have against Meloney Nunez, her employees or contract
personnel, arising out of any injury which the client may sustain while
involved in the program.
The undersigned assumes the unavoidable risks inherent in all
horse-related activities, including but not limited to bodily injury and
physical harm to horse, rider and spectator. In consideration,
therefore, for the privilege of riding and/or working and/or participating
in activities around horses at Dunn’s arena and/or Empty Acres arenas,
does hereby agree to hold harmless and indemnify Healing Reigns, Meloney
Nunez, and their employees, volunteers, or contract personnel and further
release them from any liability by the Undersigned or to any family member
or spectator accompanying the Undersigned on the premises. I have read
this release, consent to the terms of the agreement and release the
aforementioned from said liability.
Signature of
Client/Participant:_______________________________________________
Date:_________________
Signature of Parent or Guardian:
______________________________________________Date:_________________
acknowledgement of risk
In consideration of the services of Healing Reigns PLLC, Meloney
Nunez, their agents, owners, officers, volunteers, participants,
employees, and all other persons or entities acting in any capacity on
their behalf (hereinafter collectively referred to as Healing Reigns
PLLC), I hereby agree to release, indemnify, and discharge Healing Reigns
PLLC on behalf of myself, my children, my parents, my heirs, assigns,
personal representative
and estate as follows:
1. I
acknowledge that horseback riding, caring for horses, and all
therapeutic activities involving horses entail known and unanticipated
risks, which could result in physical or emotional injury, paralysis,
death, or damage to myself, to property, or to third parties. I
understand that such risks simply cannot be eliminated without
jeopardizing the essential qualities of the activity.
The Risks include, among
other things: Loss of control, collisions: Horses, irrespective of
their previous behavior and characteristics, may act or react
unpredictably based upon instinct, fright, or lack of proper control
by rider; latent or apparent defects or conditions in equipment,
animals or property, acts of the other participants in this activity,
adverse weather conditions, contact with plants, insects, or animals,
my own physical condition or my own acts or omissions, the condition
of remote roads, trails, waterways, or terrain, and accidents
connected with their use; first-aid, emergency treatment or
other services rendered; consumption of food and drink.
Furthermore, Healing Reigns
PLLC instructors have difficult jobs to perform. They seek safety, but
they are not infallible. They might be unaware of a participant’s
fitness or abilities. They might misjudge the weather, the elements,
or the terrain. They may give inadequate warnings or instructions, and
the equipment being used might malfunction.
2. I
expressly agree and promise to accept and assume all of the risks
existing in this activity. My participation in this activity is purely
voluntary, and I elect to participate in spite of the risks.
3. I hereby voluntarily release, forever discharge, and agree
to indemnify and hold harmless Healing Reigns PLLC and Mrs.
Meloney Nunez, from any and all claims, demands or causes of action,
which are in any way connected with my participation in this activity
or my use of Healing Reigns PLLC equipment or facilities, including
any such Claims which allege negligent acts or omission of Healing
Reigns PLLC.
4. Should Healing Reigns PLLC or anyone acting on their behalf
be required to incur attorney’s fees and cost to enforce this
agreement, I agree to indemnify and hold them harmless for all such
fees and costs.
5. I certify that I have adequate insurance to
cover any injury or damage I may cause or suffer while participating,
or else I agree to bear the costs of such injury or damage myself. I
further certify that I have no medical or physical conditions
which could interfere with my safety in this activity, or else I agree
to bear all costs of all risks that may be created, directly or
indirectly, by such condition.
6. In the event that I file a lawsuit against Healing
Reigns PLLC, I agree to do so solely in the state of Arizona.
I further agree that the substantive law shall
apply in such action without regard to the conflict of law rules of
that state. I agree that if any portion of this agreement is
found to be void or unenforceable, the remaining portions shall remain
in full force and effect.
Warning: Under Arizona Law, an equine activity
sponsor or equine professional is not liable for any injury to or the
death of a participant in equine activities resulting from the
inherent risks of equine activities, AZ ST 12-553.
By signing this document, I acknowledge that if anyone is hurt or
property is damaged during my participation in this activity or any
other activity involving other animals or persons, I may be found by a
court of law to have waived my right to maintain a lawsuit against
Healing Reigns PLLC on the basis of any claim from which I have
released them herein.
I have had sufficient opportunity to read this entire document.
I hereby acknowledge that I have read it and understand it and agree
to be bound by its terms.
Participant Signature:
________________________________________Print
Name:_______________________
Address: ___________________________________________________State/Zip
Code:_______________
Phone:___________________________________________
Date:_________________________________
Parent’s or Guardian’s additional indemnification
(Must be completed for participant under the age of 18)
In consideration of _____________________(print
minor’s name) (“Minor”) being permitted by Healing Reigns PLLC from
any and all Claims which are brought by, or an behalf of Minor, and
which are in any way connected with such use or participation byMinor.
Parent or Guardian:__________________________________________Date:_______________________________
Print Name:________________________
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