• Virtual Day Program Online Application

    To apply for membership please complete all questions.
  • If not, please provide the contact information for at least one person who will be available to assist the member during virtual programming:        
                

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  • Online Media Consent Form

    (must be signed by member or their legal guardian as applicable)

    I authorize HFF, its assigns and transferees to copyright, use and publish this information about me in print and/or electronically. I agree that HFF may use such information about me with or without my name and for any lawful purpose, including but not limited to such purposes as publicity, illustration, advertising, social media, and Web content.  This consent also includes the right to make such changes, fictionalizations and/or creative choices as HFF may decide in its sole discretion.  I agree not to bring any action or claim(s) against HFF and its governing board, directors, officers, employees, volunteers, and/or agents now or in the future based on the use and depiction of my information. I understand that I may revoke this release in writing if I wish for my information to be excluded from future media uses.  I understand that I cannot revoke a release of my information for which I have given prior consent for media that is already existing and/or published. 

  • Online Consent Form

    (must be signed by member or their legal guardian as applicable)

    • I am 18 years old or older and a resident of North Carolina.
    • I have a traumatic or acquired brain injury.
    • Hinds’ Feet Farm has permission to contact and share my information with the emergency contact person I have provided as well as my caregiver as needed.
    • I agree to participate in virtual programming using the Zoom platform, which is not considered to be a secure or confidential online platform.  I understand that virtual programming may be recorded.
    • I understand that physical activity, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries, and I hereby assert that my participation is voluntary and that I knowingly assume all risks .  Hinds’ Feet Farm’s virtual programs provide physical activities including but not limited to yoga, line dancing, stretching, and various group exercise classes, etc.  The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains; 2) major injuries such as eye injury, back injury, heart attacks, and concussions; and 3) catastrophic injuries including paralysis and death.   I release Hinds' Feet Farm from any and all liability arising out of my participation in any physical activities and hereby waive my rights herein to assert any action or claim(s) against Hinds' Feet Farm and its governing board, directors, officers, employees, volunteers, community instructors, and/or agents.
    • I agree to follow the rules of the Hinds’ Feet Farm virtual day program and understand that failure to follow program rules may result in my suspension or expulsion from the program:
      • Respect the views and opinions expressed by others in the group.
      • No use of illegal drugs, tobacco or alcohol during program activities.
      • No cursing or suggestive language.
      • Only the enrolled member and a caregiver are allowed in the virtual activity.
      • Must be fully dressed at all times.
      • May not threaten to harm others.
      • Keep information shared by others in the virtual activity confidential.
      • Have a contact person for us to reach out to in case of emergency or concerning behavior.
      • Hinds’ Feet Farm staff reserve the right to remove you from the virtual activity due to disruptive or threatening behavior.
      • Video must be left on at all times while participating in virtual programming.
    • I will keep all information confidential that is discussed as part of Hinds’ Feet Farm’s programs within a group setting.
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