Leadership Participant Form

Date of Event(Required)

Please tell us the date of your event or class.

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone(Required)

Work Phone

Email(Required)

Health Ins Company

Policy

Allergies

Medication

Are you Active Military or a Veteran?

yes

no

Medication(Required)

I understand that there is an inherent risk in working outdoors with animals. I understand that the information given above will only be used in the case of an emergency, should hospitalization be required. All information will be kept confidential.

I do not have a medical condition that would increase my risk or risk to others when working with horses and the outdoors.

I understand that the information provided above is accurate to the best of my knowledge. I know no reason why I should not participate in HORSEPOWER Inc.'s program.

Signature(Required)

(If rider is under age of 18 years old this must be signed by a legal guardian)

Date

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.

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 acknowledge the risks and potential for risks of equine activities, however, I feel that the possible benefits to me and the clients with whom I work 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 Horsepower Inc., its Board of Directors, instructors, therapists, volunteers, and/or employees for any and all injuries and/or losses I may sustain while participating in Horsepower Inc.'s program.

CONSENT PLAN AND AGREEMENT

In the event emergency medical aid/treatment is required due to illness or injury while being on the property of the agency, I authorize Horsepower Inc. to: Secure and retain medical treatmentand transportation as needed and 2: Release records upon request to the authorized individual or involved in the medical emergency treatment. This authorization includes, x-ray, surgery, hospitalization, medication, and any treatment procedure deemed "life saving" by the physician. This provision will only be invoked if the person(s) listed as your emergency contact is/are unable to be reached.

Please check:(Required)

I do consent

I do NOT consent

Signature(Required)

Date

Emergency Contact

Emergency Contact Name(Required)

Phone

Emergency Contact Name

Phone

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