Cloverleaf Equine Center Visitor Form

Cloverleaf Equine Center Visitor Form

Welcome! We are excited to have you here.
VisitorTourCommunity PartnerCorporate Work DayOther
YesNo
Date of Visit

MonthDayYear
Date
Reason for visit:
Visitor Information

Primary Visitor Name Required. You can add up to 3 guest visitor's to your party. As Primary Visitor, you will sign releases on behalf of your entire party.
Primary Visitor Name*

First NameLast Name
Guest Visitor Name

First NameLast Name
Guest Visitor Name

First NameLast Name
Guest Visitor Name

First NameLast Name
Current Date

MonthDayYear
Date
Print Name Parent/Guardian

First NameLast Name
Primary Visitor Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Visitor Email*
example@example.com
Primary Visitor Phone Number*
Mobile preferredFormat: (000) 000-0000.
How did you hear about Cloverleaf?
Other:

Emergency Treatment Release
Print Name Parent/Guardian

First NameLast Name
- (1) Emergency Contact Name*
  
  First NameLast Name
- (1) Emergency Contact Phone Number*
  Mobile preferredFormat: (000) 000-0000.
- (1) Emergency Contact Relationship*
  Relationship to participant
- (1) Emergency Contact Relationship (Other)
- (2) Emergency Contact Name
  
  First NameLast Name
- (2) Emergency Contact Phone Number
  Mobile preferredFormat: (000) 000-0000.
- (2) Emergency Contact Relationship
  Relationship to participant
- (2) Emergency Contact Relationship (Other)
- Please read carefully below and sign/select the appropriate option below (Consent or Non-Consent).
- In case of medical emergency, due to illness or injury during the process of receiving services, or while being on the property of the Cloverleaf Equine Center, the undersigned authorizes Cloverleaf Equine Center to:
  1. Secure and retain medical treatment and transportation if needed.
  2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
  This authorization includes x-ray, surgery, hospitalization, medication, anesthetic, and any treatment procedure deemed “life saving” by the physician. This provision will only be invoked if the person(s) above is unable to be reached.
- Consent Signature (Signature of parent or guardian if under 18)
- Date Signed (Consent)
  
  MonthDayYear
  Date
- I do not give my consent for emergency medical treatment/aid in the case of injury, illness, or during the process of receiving services or while being on the property of the Cloverleaf Equine Center.
- YesNoN/A
- In the event emergency medical treatment/aid is required, I wish the following procedure to take place:
- Non-Consent Signature (Signature of parent or guardian if under 18)
- Date Signed (Non-Consent)
  
  MonthDayYear
  Date
- ConsentNon-Consent

Release & Hold Harmless Agreement
In consideration of receiving permission from the Cloverleaf Equine Center (referred to as “The Center”) to participate in or observe equine-assisted services in further consideration of receiving permission to enter upon the Center's property or other premises upon which the Center's activities may be conducted, the undersigned and his/her family, heirs and assigns hereby forever release, acquit, discharge and hold harmless the Center, as well as its officers, directors, staff, agents, instructors, volunteers, contributors and any property or horse owners affiliated with the Center of and from any and all liability, claim, loss, damage, illness, injury, or death that may be sustained by any of the undersigned while in or upon the premises while participating in or observing activities or while traveling to or from the premises.

The undersigned acknowledges that there are certain risks inherent in participation in equine activities including (i) the propensity of an equine to behave in dangerous ways that may result in injury to the participant; (ii) the inability to predict an equine’s reaction to sound, movements, objects, persons, or animals; (iii) the possibility of equipment failure; and (iv) hazards of surface or subsurface conditions. While the Center makes every effort to minimize these risks, the undersigned is duly aware of these risks and hazards inherent upon participation in or observing equine activities and/or upon entering upon the premises and expressly and knowingly assumes these risks. The undersigned shall explain the potential for these hazards and risks to others that may accompany or substitute for him/her at activities sponsored by the Center. These persons also, by their voluntary presence, assume the same risks and agree by their presence to the same release of liability described herein.

The undersigned shall release and hold harmless the Program, its officers, trustees, agents, instructors, volunteers, contributors, and other property or horse owners affiliated with the Program of and from any and all liability, claim, loss, damage, cost, charge, and demand of any kind, including attorney’s fees and any related costs, arising either from the improper or negligent use by the undersigned of any equine, bridle, saddle, grooming tool, and/or other animal or tool or from the willful or negligent acts of the undersigned.
HHA Signature (Signature of parent or guardian if under 18)*
Date Signed (HHA)*

MonthDayYear
Date

News & Photo Release
For valuable consideration given and which is hereby acknowledged, the undersigned hereby grants permission to the Cloverleaf Equine Center to take or have taken, still and moving photographs and films including television pictures of my daughter/son/ward/self, and consents and authorizes the Cloverleaf Equine Center, PATH Intl., news media, and any other persons interested in the subject of equine-assisted services and its work, to use and reproduce the photographs, films and pictures and to circulate and publicize the same by all means including and without limiting the generality of the foregoing newspapers, television media, brochures, pamphlets, books, social media including Facebook, instructional material and clinical material.

With respect to the foregoing matters, no inducements or promises have been made to me to secure my signature to this release other than the intention of the Cloverleaf Equine Center to use or cause to be used such photographs, films, or pictures for the primary purpose of promoting and aiding the field of equine-assisted services and its work.
I DO grant permissionI DO NOT grant permission
NPR Signature (Signature of parent or guardian if under 18)*
Date Signed (NPR)*

MonthDayYear
Date
Assumption of Risk, Policy Adherence and Waiver of Liability Relating to Infectious Diseases
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization.
COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact.

The Northern Virginia Therapeutic Riding Program (NVTRP) has put in place preventative measures to reduce the
spread of COVID-19; however, NVTRP cannot guarantee that our participants and volunteers will not become
infected with COVID-19. Further, attending NVTRP activities could increase your risk of contracting COVID-19.
Please be advised that there are inherent risks when participating in equine-assisted activities and therapies
such as:
- Leather equipment (such as reins and saddle) cannot be completely disinfected.
- Staff and volunteers often must be hands-on in assisting clients and will not be able to practice social
  distancing at all times.
There are also some issues that may INCREASE their inherent risk of infection such as:
- Underlying medical condition or age over 60.
- Struggles to maintain social distancing.
- Unable to comply with wearing a mask.
- Touches face/mouth frequently, drools.
By signing this agreement,

I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I (or my child if under 18) may be exposed to or infected by COVID-19 by attending sessions at NVTRP and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at NVTRP may result from the actions, omissions, or negligence of myself and others, including, but not limited to, NVTRP employees, volunteers, and program participants and their families. Initials (1)

Please initial next to each bullet indicating your agreement with the following statements:
- Initials (2) I have read and agree to adhere to NVTRP’s Procedures and Safety Precautions, including the new Sick Policy and Mitigation Measures to help stop the spread of COVID-19.
- Initials (3) I understand that if I do not abide by NVTRP’s Procedures and Safety Precautions, including the new Sick Policy and Mitigation Measures, NVTRP can deny participation.
COVID-19 Policy Signature (Signature of parent or guardian if under 18)
Date Signed (COVID-19 Policy)

MonthDayYear
Date
Please review and verify all your information is correct, then Submit.
Should be Empty:

Cloverleaf Equine Center Visitor Form

Visitor Information

Emergency Treatment Release

Release & Hold Harmless Agreement

News & Photo Release

Assumption of Risk, Policy Adherence and Waiver of Liability Relating to Infectious Diseases