Visitor Form

Primary Visitor Name:*

First NameLast Name

List all visitors under 18 here (for groups/families):

Purpose for farm visit:*

Phone Number*

Please enter a valid phone number.

Parent/Guardian's Name (if under 18)

First NameLast Name

Parent/Guardian Phone Number (if under 18)

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Emergency Contact/Phone #*

Five Hearts TH Barn Rules (Please Read):

No Smoking/Vaping anywhere on the premises
Clean up after yourself - EVERYWHERE!
Sign all required liability release forms
Volunteers must sign in/out
Use calm voices while in the barn and around horses
No running around horses
Please do not feed horses treats without asking first
Take private conversations elsewhere
No profanity/inappropriate conversations
Wear modest/appropriate clothing
Closed toed shoes required around barn and horses
Helmets must be worn by anyone under 18 years old
Children under 12 must be supervised by an adult at all times
Only use equipment/supplies that belong to Five Hearts TH
Turn off lights when not in use
Keep all gates closed
ALWAYS BE KIND!

Liability Release

I recognize that participation in the activities in the Five Hearts Therapeutic Horsemanship program AND 3 Bluebirds Farm located at 5101 Holland Church Rd. Raleigh, NC 27603 (“the facility”) involves significant hazards and risks in riding and handling horses. I certify that neither I nor the participant for which I am responsible has any physical conditions which might interfere with my/his/her capacity to participate in horseback riding and other activities offered by the Five Hearts Therapeutic Horsemanship program and 3 Bluebirds Farm. Knowing the inherent risks, dangers and rigors involved in physical labor, horseback riding, and other activities involving horses, I assume full responsibility for myself or the participant for which I am responsible for any and all bodily injury, death, loss of personal property and expenses thereof, which may occur as a result of participation in physical labor, the handling of horses, horseback riding and other activities sponsored by the Five Hearts Therapeutic Horsemanship program or may occur at the 3 Bluebirds Farm facility. I waive any and all claims which may result from any such participation. I expressly release and waive all such liability and claims, even if they should arise out of the negligence of other persons, including other persons released hereby. I further agree that if anyone makes any claim on my behalf or on behalf of the participant for which I am responsible because of any injury, death or damage to property, I will indemnify and hold harmless all of those persons released by this agreement against any damage, or costs which may result because of those claims, including legal fees.

I will observe all rules, regulations and instructions of the facility and will exercise due care to avoid injury, damage or loss to person and property. I certify that I have received a copy of the current rules and policy and understand that any infractions of the rules may terminate any business I have with the program or right to participate in the program.

The persons and entities which are hereby released and to which the benefit of this liability and release adheres are Five Hearts Therapeutic Horsemanship, Inc., 3 Bluebirds Farm and its employees, volunteers, participants, guardians, officers, directors and any other person connected to or participating in the Five Hearts Therapeutic Horsemanship program on the property of 3 Bluebirds Farm.

I have read, understand and agree to the terms and conditions stated herein. I acknowledge that this agreement shall be effective and binding upon me and the participant for whom I am responsible during the entire period of my/his/her participation in physical labor, the handling of horses and/or the participation and therapeutic riding lessons upon the premises of the facility at 3 Bluebirds Farm.

The undersigned understands that under North Carolina Law an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting exclusively from the inherent risks of equine activities. Chapter 99E of the North Carolina General Statutes.

SIGNATURE OF PARTICIPANT AND PARENT/GUARDIAN OF VISITOR UNDER 18.

Signature - Liability Release Form*

Printed Name:*

Signature of Parent/Guardian (if under 18) - Liability Release Form

Printed Name:

Photo/Video Release (Please choose either Consent or Non-Consent)*

I consent to and authorize the use and reproduction by Five Hearts Therapeutic Horsemanship of any and all photographs and any other audio-visual materials, including videotape, taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.I do not give my consent nor do I authorize the use and reproduction by Five Hearts Therapeutic Horsemanship of any photographs or any other audio-visual materials taken of me.

Signature - Photo/Video Release*

Printed Name:

Signature of Parent/Guardian (if under 18) - Photo/Video Release

Printed Name:

Confidentiality Policy

Because of the nature of the program, Five Hearts Therapeutic Horsemanship Program may have access to confidential medical and financial records of riders. To protect the confidentiality of our riders, Five Hearts Therapeutic Horsemanship has instituted a confidentiality policy. Five Hearts Therapeutic Horsemanship Program shall preserve the right of confidentiality for all riders participating in its program. Individuals bound by this policy include part and full time staff members, volunteers who may have access to confidential knowledge, independent contractors involved with the program, instructors and board members. Individuals subject to this policy shall keep confidential any and all medical, social, referral, personal, and financial information regarding a person and/or his or her family. All riders or rider parent(s), legal representatives, or others as defined by state stature must sign consent or non-consent release forms regarding medical and sensitive information disclosure, and consent or non-consent release forms regarding use of photography and/or videotape prior to participation in the program. Penalties for breach of confidentiality shall include the immediate loss of any responsibilities that would allow the individual access to confidential records. Additional penalties may include, at the discretion of the board of directors, reprimand, loss of certain job responsibilities, and/or termination from the program.

I understand and will observe the confidentiality policy of Five Hearts Therapeutic Horsemanship.

Signature - Confidentiality Policy*

Printed Name:

Signature of Parent/Guardian (if under 18) - Confidentiality Policy

Printed Name:

Visitor Information & Release