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Camp Application Form
Step
1
of
6
16%
Participant Information
Participants Name
First
Middle
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
Date of Birth
MM slash DD slash YYYY
Parent(s)/ Legal Guardian Information
Parent(s)/ Legal Guardian Name
First
Last
Employer
Work Number
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Mobile
Medical Information
Physicians Name
Medical Facility
Phone
Health Ins. Company
Policy #
Allergies
Medication
Health History (Fitness, Respiratory. bone & Joint function. recent surgery)
Photo Release
Photo Release (Please check)
I do
I do not
Photo Release (please check): I do ( ) or I do not ) Consent to and authorize the use and reproduction by HORSEPOWER Inc. of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions, or for any other use for the benefit of the program.
Signature
(If Student is under age of 18 years old this must be signed by a legal guardian)
Date
MM slash DD slash YYYY
Emergency Treatment Release Form
(Please choose either Consent Plan and Agreement or Non-Consent Plan)
Consent Plan and Agreement:
Initial
In the event emergency medical aid/treatment is required due to illness or injury while being on the property of the I authorize HORSEPOWEI Inc. to 1: Secure and retain medical treatment and transportation as needed and 2: records upon request to the authorized individual or agency involved in the medical emergency treatment. This authorization includes, x ray, surgery, hospitalization, medication, and any treatment procedure deemed "life saving" by physician. This provision will only be invoked if the person(s) below is/are unable to be reached.
Consent Plan and Agreement Signature
(If Student is under age of 18 years old this must be signed by a legal guardian)
Date
MM slash DD slash YYYY
Non-Consent Plan
Initial
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency.
Untitled
Parent or legal guardian will remain on site at all times during equine assisted activities
In the event emergency treatment/aid is required, I wish the following procedure to take place:
Only answer if you chose Non-Consent Plan
Client's Name
(Client's Name) would like to participate in the HORSEPOWER Inc., program. I acknowledge the risks and potential for risk of Horseback Riding. However, I feel that the possible benefits to me/my son/my daughter/my ward are greater than the risk assumed. I hereby, in tending to be legally bound, for me, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against HORSE POWER Inc., its Board of Directors, instructors, Therapists, Aides, Volunteers and/or Employees for any and all injuries and/or losses I/my son/my daughter/my ward while participating in HORSEPOWER Inc.
Consent Signature
(If Student is under age of 18 years old this must be signed by a legal guardian)
Date
MM slash DD slash YYYY
Emergency Contact
In the event of an emergency, Please contact:
Name
First
Last
Phone
Relationship
Second Emergency Contact
Name
First
Last
Phone
Relationship
RELEASE OF LIABILITY AND INDEMNITY AGREEMENT
RELEASE OF LIABILITY AND INDEMNITY AGREEMENT I hereby agree to indemnify and hold harmless and release Horsepower Inc., its officers, members, agents and volunteers from any and all liability for injury, damages or harm that may occur to me, my representatives, heirs, dependents, guests, or to the equine I am using, or to the property owned or used by me. Further, I represent that I understand the hazardous nature of using equines, including pleasure riding, in which injury can occur to equine and rider due to vehicles, natural and man-made obstacles or materials, other equines, dogs, storms, uneven terrain, stress, and other hazards. I further understand that I am not riding as an employee but as a volunteer and on my own time. I am covered under my personal insurance and not under workers compensation or HORSEPOWER's insurance. WARNING Under North Carolina law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting exclusively from the inherent risks of equine activities. - Chapter 99E of the North Carolina General Statutes Definition of inherent risks of equine activities: those dangers or conditions that are an integral part of engaging in an equine activity, including any of the following: a. The possibility of an equine behaving in ways that may result in injury, harm or death to person(s) on or around them. b. The unpredictability of an equine's reaction to such things as sounds, sudden movement, unfamiliar objects, person(s), or other animals.
Participant's Name
First
Last
Participant's Signature
Date
MM slash DD slash YYYY
Parent/Guardian's Name
First
Last
Parent/Guardian's Signature
Parent/Guardian's Signature If participant underage of 18 yrs old
Date
MM slash DD slash YYYY
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