2020 SH Sibling Equestrian Program

Participant's Full Name:

DOB (Must be at least 5 years old to participate.):

Address:

City:

State:

Zip:

Home Phone:

Parent/Legal Guardian:

Address (if different from above):

Cell Phone:

Email Address:

example@example.com

List any Allergies:

List any/all Medications:

List any/all Medical Conditions:

In Case of Emergency Contact Name:

Relationship:

Phone:

Please Choose A Date and Time for Your Session: *

August 24th at 1:30 pm August 31st at 1:30pm

Do you consent to and authorize the use and reproduction by Whispering Manes Therapeutic Riding Center of any and all photographs and any other audio/visual material taken of me for promotional material , educational activities, exhibitions, or for any other use for the benefit of the program? *

In the event of an emergency medical aid/treatment due to illness or injury while present on the property of Whispering Manes, DO YOU AUTHORIZE Whispering Manes to secure transportation and medical treatment including x-ray, anesthetic, surgical or medical diagnosis or treatment and hospital service rendered under the general or specific instructions of a physician or hospital? And do you agree to pay all fees and expenses of doctors, hospitals, ambulances and other medical expenses reasonably and necessarily incurred? *

We are required by law to maintain the privacy of, and provide individuals with, this notice of legal duties, and privacy practices with respect to your protected medical information. If you have any objections to this form, please ask to speak to the Executive Director. Do you acknowledge that you have read Whispering Manes Therapeutic Riding Center's privacy policy (see below)? *

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

I also understand that upon arrival to Whispering Manes Therapeutic Riding Center (WMTRC) for my/my child's session, I or parent /legal guardian will be available to sign WMTRC waivers and releases.

I also understand that I must bring to scheduled session completed WMTRC Physician Form for each sibling participating in the program. Click here to download required form.

NOTE: If necessary, parent/legal guardian may be asked to be sidewalker during their child's lesson so please dress accordingly (pants and closed-toe shoes).

Signature of Participant or Parent/Guardian, if minor: *

Clear

Printed Name: *

Date:

Date

Sofia's Hope, Inc. Waiver & Liability Release

This Participant Waiver & Liability Release, Waiver of Right to Sue and Assumption of All Risks Agreement ("the Agreement") is hereby given by on his/her own behalf as a participant, AND/OR by the parent or guardian of the above named minor who is a participant in or to any program, activity or event taking place under the sponsorship of Sofia's Hope, Inc., a Florida not-for-profit corporation located at 10106 SW 126 Street, Miami, Florida (referred to herein as “Sponsor ”).

The purpose of this agreement is to exempt, waive and relieve Sponsor from any and all liability for wrongful death, personal injury, and property damage, including, but not limited to, liability arising from the negligence of Sponsor. "Sponsor" include Sofia's Hope, Inc. and their representatives, administrators, directors, agents, coaches, employees, and volunteers; other participants, sponsoring agencies, sponsors, and advertisers; and, if applicable, the owners, operators, and lessors of premises on which the activities or events take place.

The Undersigned ("Undersigned" means only the Participant when the Participant is age 18 or older or it means both the Participant and the Participant's parent or legal guardian when the Participant is under the age of 18) agrees and acknowledges as follows:

1. Risks of Activity. Participant will be taking part in activities that can be hazardous and involve the risk of physical injury and/or death. The activities are inherently dangerous and Undersigned fully realizes the dangers of participating in the activities. The dangers and risks of the activities include, but are not limited to the condition of the premises and equipment, and the acts, omissions, representations, carelessness, and negligence of the Sponsor. Recognizing the risks and dangers, the Undersigned voluntarily chooses for Participant to participate in the activities and expressly assumes all risks and dangers of the participation in the activity, whether or not described above, known or unknown, inherent, or otherwise.

2. Release and Indemnification. Undersigned (a) unconditionally releases, forever discharges, and agrees not to sue the Sponsor for any claims or causes of action for any liability or loss of any nature, including personal injury, death, and property damage, arising out of or relating to Participant's participation in the activities, including, but not limited to, claims of negligence, breach of warranty, and/or breach of contract the Undersigned may/or will have against the Sponsor; and (b) agrees to indemnify, defend, and hold harmless the Sponsor from and against any liability or damage of any kind and from any suits, claims or demands, including legal fees and expenses, whether or not in litigation, arising out of, or related to, Participant's participation in the activities.

3. Miscellaneous. Undersigned agrees (a) Participant will not engage in any activities prohibited by any applicable laws, statutes, regulations and ordinances; (b) this agreement shall be governed by the laws of the State of FL and the exclusive jurisdiction and venue for any claim shall be located in the state courts located in Miami-Dade County, FL; and (c) this agreement shall be binding upon the subrogors, distributors, heirs, next of kin, executors, and personal representatives of the Undersigned. This RELEASE shall cover all incidents arising at anytime throughout the duration of any and all activities contemplated herein, and shall remain in full force and effect from the date of this RELEASE forever.

Undersigned parent or legal guardian acknowledges that he/she is not only signing this Agreement on his/her behalf, but that he/she is also signing on behalf of the minor and that the minor shall be bound by all the terms of this agreement. Additionally, by signing this agreement as the parent or legal guardian of a minor, the parent or legal guardian understands that he/she is also waiving rights on behalf of the minor that the minor otherwise may have. The Undersigned parent or legal guardian agrees that, but for the foregoing, the minor would not be permitted to participate in the activities. If signing as the parent or guardian of a minor Participant, signing adult represents that he/she is the legal parent or guardian of the minor Participant.

PHOTO RELEASE

Further, Participant consents to and authorizes the reproduction and use by Sponsor of any and all photographs and any other audio-visual materials taken of Participants for promotional materials, new publications, educational activities, exhibitions or for any other use for the benefit of the Sponsor. I have read and understand this RELEASE and voluntarily agree to be legally bound to its terms and conditions.

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND ITS CONTENTS. I AM AWARE THAT I AM RELEASING LEGAL RIGHTS THAT OTHERWISE MAY EXIST.

Signature of Participant or Parent/Legal Guardian, if a minor: *

Clear

Printed Name: *

Date:

Date

Equine Release and Waiver of Liability, Assumption of Risk and Indemnification Agreement

WARNING

CAUTION: HORSEBACKRIDING CAN BE DANGEROUS. RIDE AT YOUR OWN RISK.

Under Florida law an equine activity sponsor or equine professional is not liable for any injury to, or the death of, a participant or a volunteer in equine activities resulting from the inherent risks of equine activities.

FLORIDA STATE STATUTE 773.04

If the participant or volunteer is a minor or legal ward, THEN A LEGAL GUARDIAN MUST sign below on behalf of the minor/legal ward. NOTE: No minor or legal ward will be allowed to participate or volunteer in the Activities unless accompanied by an adult.

Signature of Participant or Parent/Legal Guardian, if a minor: *

Clear

Printed Name: *

Date:

Date

Re-Opening Policies During Coronavirus Pandemic

We plan to re-open our facility in phases:

Phase I – Each Rider must meet the following criteria:

Rider must be independent, riding without a horse handler or side walker(s) as of March 13, 2020.
Rider must be able to mount and dismount without direct support of the instructor.
Classes may be walk only based on the instructor’ discretion.

Phase II - Rider must meet the following criteria:

Rider must be independent requiring only a horse handler or spotter. Rider must be able to ride without the support of sidewalkers as of March 13, 2020.
Rider must be able to mount and dismount with minimal support of the instructor. Rider who require lifting, or significant support to mount or dismount are not eligible to ride in Phase II.
Classes may be walk only based on the instructor’s discretion.
Rider in Phase II must wear face masks.

Ongoing Eligibility Requirements:

Each Rider and anyone in the Rider’s household must be free of the following symptoms and/or conditions for 24 hours prior to arriving at the barn. Symptoms/ conditions include but are not limited to those listed below. Participants and Participant Representatives must keep up to date on changing CDC and local government guidelines.

Temperature or fever of over 100 F
- Fever must remain absent for 24 hours without use of Tylenol, Motrin or other anti-pyretic medications.
Two or more cold/flu/COVID-19 symptoms, including but not limited to muscle pain, headache, sore throat, cough, chills.
- Symptoms must be absent for 24 hours without use of Tylenol, Motrin or other medications.
Cloudy discharge from eyes
Colored mucus discharge from nose
Undiagnosed rash on body
Vomiting and/or diarrhea

If you, the Participant, your child, anyone in your household, or anyone you have had contact with are exhibiting any of these symptoms, please contact the Whispering Manes Program Director immediately to cancel the scheduled session. We reserve the right to cancel the lesson upon your arrival or the Participant’s arrival at the facility if you or the Participant display any symptoms described above.

Additional Policies:

All lessons are 30 minutes, with 30 minutes in between lessons to allow for cleaning/disinfection of equipment and facilities between riders.

Each Rider is required to purchase/bring their own ASTM approved horseback riding helmets.

Only one person can accompany the Rider to the facility.

Participant Representative must remain in car while Participant is attending his/her lesson. Cars can be parked in view of the covered arena.

Each Rider must clean hands with sanitizer before and after classes.

All areas (tack room, bathrooms, water fountains, etc.) are off-limits to everyone except to staff.

If a Rider arrives late for the lesson, the Rider may be charged even if the Rider does not have time to ride because we are practicing social distancing and the lessons will be scheduled to ensure no overlap between Riders.

Whispering Manes will take the following measures between Riders:

Instructor will wash hands between Riders.

Horse handlers/spotter will wear a mask during classes.

Hard surfaces, railings, gates, etc. will be cleaned/wiped with appropriate disinfectant.

Instructor will wear face mask when coming within 6 ft of Rider (ie., check helmet fit, tack checks, etc.).

Tack will be wiped with appropriate leather cleaners in between Riders.

Reins will be changed between Riders. Reins will be cleaned daily in washing machine and dryer.

Saddle pads will be changed in between horses and washed in the washing machine on a daily basis.

Signature of Participant or Parent/Legal Guardian, if a minor: *

Clear

Printed Name: *

Date:

Date

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out the formulation of a riding program and/or participation at Whispering Manes Therapeutic Riding Center (WMTRC), and/or for payment and for other purposes that are permitted or requited by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, out office staff and others outside of our office that are involved with you for the purpose of your participation at WMTRC and any other use required by law.

Treatment

We will use and disclose your protected health information to provide, coordinate, or manage your participation at Whispering Manes and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a staff member or volunteer to assist them in helping you.

Payment

Your protected health information may be used, as needed, to obtain payment for your services.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures

Will be made only with your consent, authorization or opportunity to object, unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that WMTRC has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records, psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposed as described in this Notice of Privacy Practices. Your request must state the specific restriction and to whom you want the restriction to apply.

WMTRC is not required to agree to a restriction that you may request. If they believe it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another riding program.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice form us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a stamen of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provide in this notice.

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have bee violated by us. You may file a complaint with us by notifying our private contact of your complaint. We will not retaliate against you for filing a complaint.

Sofia's Hope Equestrian Program for Siblings of Children with Cancer at Whispering Manes Therapeutic Riding Center (WMTRC)