Recreational Horsemanship Application

Recreational Horsemanship Lesson Participant Information

As a nonprofit organization, we rely heavily of grants that require us to report demographic information about our participants. Thank you for providing this information so that we can continue to provide our high-quality programs at the lowest cost possible. All information is protected by our confidentiality policy.
Name

First Name Last Name
Date of Birth *

Month Day Year
Age *
Gender *
Height *
Weight *
Primary Phone (please tell us if it is cell or home ) *
Email Address
Street Address *
City *
Zip Code *
School/Institution/Employer Name
Does the participant wear a mask?

Yes No
Is the Participant a *

Minor Adult with Legal Guardian or Caregiver Independent Adult Veteran
Are there children in foster care currently residing in the home? *

Yes No
Does the participant speak a language other than English at home? *

Yes No
Does the participant's household qualify for Oregon’s free/reduced lunch program? *

Yes No
What is the Participant's racial/ethnic background? *

Asian Middle Eastern Black/African American Native American/Alaskan Native Caucasian/White Pacific Islander Hispanic/Latino
Is the participant considered part of a vulnerable, underserved or underrepresented population? (Vulnerable and underserved populations generally include the economically disadvantaged, experiencing homelessness, low-income, racial and ethnic minorities, members of the LGBTQ+ community, youth with trauma related adverse childhood experiences, children with incarcerated parents, or individuals experiencing physical or mental challenges.) *

Yes No
For minors or adults with legal guardians/caregivers:
Parent or Guardian Name
Phone Number

Area Code Phone Number
Email Address
Who can we thank for telling you about us?
Individual Name:
Agency/Organization Name:
Please describe the participant's experience with horses? *
Please list all medication (including medical marijuana) *
Participant's overall health: *

Poor Fair Good Excellent
Please note any health concerns, allergies and EpiPen or inhaler used: *
Please share a little about yourself/participant including hobbies, goals and/or a fun fact. *
The information provided is, to my knowledge, accurate and current.
Electronic Signature: *
I am (check one): *

Participant Participant's Parent Participant's Legal Guardian
Date: *

Month Day Year
Participant Consent & Release Form

CONSENT FOR EMERGENCY MEDICAL TREATMENT: In the event of an emergency, if medical aid/treatment is required due to illness or injury while participating in the services of, or while being on the property of, Healing Reins Therapeutic Riding Center (“HRTRC”), an Oregon non-profit corporation, I authorize HRTRC to secure and retain medical treatment and/or transportation if needed. This authorization includes any treatment deemed necessary by a treating health care professional and includes, but is not limited to, x-ray, surgery, hospitalization, and medication. In addition, I authorize HRTRC to release my/my child/my ward’s records to any individual involved in medical treatment and/or necessary transportation. LIABILITY RELEASE: Under Oregon Law, an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of participating in equine activities, pursuant to section 30.691, Oregon Revised Statutes. I would like to participate in HRTRC’s program. I acknowledge the risks and potential for risks in riding and working with horses. However, I feel that the possible benefits to myself/my child/my ward are greater than the risks assumed. Intending to be legally bound, for myself and my heirs, assigns and legal representatives, I hereby forever waive and release any and all claims, whenever arising, against Faith Run Farms, LLC (“FRF”) an Oregon limited liability company, HRTRC, and their respective directors, officers, members, employees, agents and representatives arising from, or relating in any way to my/my child’s/my ward’s participation in any HRTRC program or presence on the FRF property generally.
I accept and agree to the terms and conditions listed above. *

Agree
Photo & Publicity Release

I DO/ I DO NOT Consent to and authorize the use and reproduction by Healing Reins Therapeutic Riding Center 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.
*

I DO I DO NOT
Participant Signature OR Parent/Guardian Electronic Signature if participant is a minor or has a legal guardian *
Date Signed *

Month Day Year
Emergency Contact Information
Emergency Contact 1 *
Relationship to Participant *
Phone Number *
Should be Empty:

Recreational Horsemanship Lesson Participant Information

For minors or adults with legal guardians/caregivers:

Who can we thank for telling you about us?

The information provided is, to my knowledge, accurate and current.

Participant Consent & Release Form

Photo & Publicity Release

Emergency Contact Information