Clinic Registration

Spring into Balance Clinic

At Heaven's Gate Farm: 5590 Bradshaw Road, Pipersville, Pa 18947 C: (215) 964-1476
"An Equestrian is responsible for the health and well-being of each horse we care for. We have a duty to continuously evaluate our methods and beliefs in order to develop knowledge and wisdom that prioritizes the horse." -Jessica
Participant or Auditor Name*

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Parent or Guardian Name if Participant is a child

First NameLast Name
Email a riding/auditing release form will be emailed to you*
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Address*

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Emergency Phone Number
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Please read and double-check your selection(s) here, payment in advance is required with NO REFUNDS after submitting this form. You will check in with the clinic secretary and receive a wristband at the door. Light snacks will be provided, please bring your lunch and a comfy seat. Along with your tack, please bring a well fitting rope halter with a 12 foot lead. Please let me know if you have any questions. The rope halters I use and love can be purchased at: https://www.brentgraef.com/shop/horse-gear/halter/halter-and-lead-rope/

AuditorUnlimited Auditors welcome.

$25.00 Quantity

Clinic ParticipantUnmounted session and mounted group lessons in clinic style

$100.00 Quantity
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Informed Consent and Acknowledgement

Please read carefully and sign below
I here by give my approval for myself or for my child’s participation in any and all activities prepared by Jessica Lyons Horsemanship LLC during the selected product/event.*

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Photo/Video Release:

I hereby permit Jessica Lyons Horsemanship LLC to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.

I understand and agree that all photos will become the property of Jessica Lyons Horsemanship LLC and will not be returned.

I hereby irrevocably authorize Jessica Lyons Horsemanship LLC to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose.

In addition, I waive any right to inspect or approve the finished product wherein my likeness appears.

Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge Jessica Lyons Horsemanship LLC from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW.
Signature*

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Medical Authorization

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As a participant, auditor, Parent, and/or Guardian I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the auditor/participant, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the medical professionals to proceed with any medical or minor surgical treatment, x-ray examination, and immunizations for the named auditor or participant.

In the event of an emergency arising out of serious illness, the need for major surgery, or a significant accidental injury, I understand that the medical professionals will make every attempt to call the contacts provided in the most expeditious way possible.

This authorization is granted only after a reasonable effort has been made to reach the contacts provided above.

Permission is also granted to Jessica Lyons Horsemanship LLC, Heaven's Gate Farm LLC and their affiliates including Owners, Directors, Instructors, Volunteers, Trainers, and Parents to provide any layman's care or treatment before the child’s admission to the medical facility.

This release is authorized for the dates and/or duration of this event.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances to protect the life and limb of the Auditor and/or Participant.
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Jessica Lyons Horsemanship LLC

(215) 964-1476 JessicaLyonsHorsemanship.com
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Spring into Balance Clinic

Informed Consent and Acknowledgement

Medical Authorization

Jessica Lyons Horsemanship LLC