Pony Partners Intake Form

Name*

First NameLast Name

Child's Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Emergency Phone Number

Please enter a valid phone number.

What would you like your child to gain from his or her time at Pony Partners?

SPECIAL NEEDS

Pony Partners often uses photographs of participants in advertising and promoting the program. We will not use photographs that show faces unless we have your express permission.

I AGREE to allow photographs of myself and/or my children to be used for promotional purposes.I AGREE To put my name on the Pony Partners Email List so that I can receive news, stories and other information. You mayunsubscribe at any time.

RELEASE OF LIABILITY AND HOLD HARMLESS AGREEMENT

In consideration for allowing me and my minor children to participate in activities and programs, including, but not limited to working with the horses, and on behalf of myself, my child or children, or our personal representatives, next-of-kin, spouses and assignee’s, I hereby freely and voluntarily enter into this Release and Hold Harmless Agreement with PONY PARTNERS (officers, volunteers and employees), and property owner Patricia Fields.

I RELEASE, DISCHARGE AND PROMISE NOT TO SUE PONY PARTERS, doing business under its own name or any other name or parent or subsidiary company and/or any of its board of director members, officers, instructors, volunteers, employees and agents (hereafter referred to as “releasees”) for any loss, liability, damages or costs whatsoever arising out of or related to any loss, damages or injury (including death) to my person or property.

1. Participant understands that there are risks inherent in dealing with horses and ponies (equine activity). For example, Participant understands that some of the inherent risks include:

a. The propensity of an equine to behave in ways that may result in injury, death, or loss to persons on or around the equine;
b. The unpredictability of an equine’s reaction to sounds, sudden movements, unfamiliar objects, persons, or other animals;
c. That there may be hazards, including, but not limited to, surface or subsurface conditions;
d. The possibility of a collision with another equine, another animal, a person, or an object;
e. The potential of an equine activity Participant to act in a negligent manner that may contribute to injury, death, or loss to the person of the Participant or to other persons, including, but not limited to, failing to maintain control over an equine or failing to act within the ability of the Participant.

With this Waiver I accept notice of the provisions of The Equine Activity Liability Act of the code of Virginia 3.2-6202. Liability limited; liability actions prohibited

A. Except as provided in § 3.2-6203, an equine activity sponsor, an equine professional, or any other person, which shall include a corporation, partnership, or limited liability company, shall not be liable for an injury to or death of a participant resulting from the intrinsic dangers of equine activities and, except as provided in § 3.2-6203, no participant, participant's parent or guardian, or representative of such parent or guardian, shall have or make any claim against or recover from any equine activity sponsor, equine professional, or any other person for injury, loss, damage, or death of the participant resulting from any of the intrinsic dangers of equine activities.

B. Except as provided in § 3.2-6203, no participant or parent or guardian of a participant who has knowingly executed a waiver of his rights to sue or agrees to assume all risks or intrinsic dangers of equine activities may maintain an action against or recover from an equine activity sponsor or an equine professional for an injury to or the death of a participant engaged in an equine activity. The waiver shall give notice to the participant of the intrinsic dangers of equine activities and may be executed at a location other than that of the equine activity. The waiver shall remain valid unless expressly revoked in writing by the participant or his parent or guardian. For purposes of this section, in the case of a minor participant, the execution of a waiver by a duly authorized representative of the parent or guardian designated in writing by the parent or guardian shall constitute a valid and knowing execution of a waiver by the parent or guardian.

2. By signing this waiver, Participant agrees that Participant has been given sufficient time to read, understand, and ask questions, if any, concerning the nature and scope of this Voluntary Waiver Agreement.
Parent or Guardian if Participant is a minor: I acknowledge my signature on behalf of any minor children shall render these provisions applicable and binding to such minor child or children as though they were parties to this agreement.

Signature*