Consent and Release Form
For parents, caregivers, participants, volunteers and guests of Healing Reins
Location:
65325 Cline Falls Rd, Bend OR 97701
Individual Name
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First Name
Last Name
I am at Healing Reins as a:
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Participant
Parent or Caregiver
Guest
Volunteer
School or Group:
Phone Number
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Area Code
Phone Number
Email
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example@example.com
Date of Birth
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Month
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Day
Year
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Age
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Gender
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Today's Date:
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Month
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Day
Year
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Participant Medical Consent & Liability Release
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, an Oregon non-profit corporation, I authorize Healing Reins 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 Healing Reins 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 Healing Reins' 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 Healing Reins, 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 Healing Reins program or presence on the Healing Reins property generally.
I accept and agree to the terms and conditions listed above.
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Agree
Participant or Guardian Electronic Signature:
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Photo & Publicity Release
I DO/ I DO NOT Consent to and authorize the use and reproduction by Healing Reins 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.
Choose one option
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I DO
I DO NOT
Participant Electronic Signature
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Submit
Should be Empty: