WORKSHOP REGISTRATION

Horse Heritage Educational Program
WORKSHOP REGISTRATION - YOUTH
Name
DOB
Age
Parent or Guardian (if under 18)
Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Phone
Alternate Phone
Employer / School
Email
example@example.com
How did you hear about Horse Heritage?
Gender

Type a question

	No	Yes	Comments
Do you have any physical complaints or illness at this time?
Are you under the care of a physician or practitioner of any sort?
Are you taking any type of medication?
Are you on a special diet?
Do you have Diabetes?
Do you have Asthma?
Do you have allergies?
Are you current on tetanus?

Other conditions or comments
EMERGENCY MEDICAL TREATMENT
Emergency Contact
Relationship
Phone
Emergency Contact
Relationship
Phone
Medical conditions requiring special consideration/treatment
Allergies
Current medications & dosage
Consent Plan
In the event emergency medical aid/treatment is required due to illness or injury during the process of volunteering, or while being on the property of the agency, I authorize Horse Heritage Educational Program to: 1. Secure and retain medical treatment and transportation if needed. 2. Release volunteer records upon request to the authorized individual or agency involved in medical emergency treatment. This authorization includes x-ray, surgery, hospitalization, medication 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.*

Clear
Parent Name Printed
Date

MonthDayYear
Date
PHOTO RELEASE
I consent to and authorize the use and reproduction by Horse Heritage Educational Program 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.
Signature of Participant*

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Date

MonthDayYear
Date
Signature of Parent*

Clear
Date

MonthDayYear
Date
WAIVER OF LIABILITY
To the Parent(s)/Legal Guardian(s): During the time your child, {name}, a minot is participating in programs using Horse Heritage Educational Program’s horses and facilities, he/she will be expected to participate in many activities associated with horsemanship. Precaution and the safety of your child is of the utmost importance. Horse Heritage Educational Program, however, requests your signature in agreement with the following statement.
- I/We, the undersigned, in full recognition of the possible dangers and hazards inherent in any activity involving horses, do hereby agree to assume all the risks and responsibilities surrounding my child’s participation in programs using Horse Heritage Educational Program horses and horse facilities; and further hereby defend, hold harmless, indemnify and release and forever discharge Horse Heritage Educational Program, and its staff members, from and against any and all claims, demands and actions on account of damage to personal property, injury, or death, which may result from my child’s participation in programs utilizing Horse Heritage Educational Program’s horses and horse facilities, which result from causes beyond the control of and without the fault or negligence of Horse Heritage Educational Program, or its employees/volunteers, during the period of my child’s participation in the aforementioned program.
- All minor participants are required to wear approved equestrian helmets. If you do not have an ASTM/SEI approved helmet, Horse Heritage Educational Program will provide one to you for the program activities.
- Under Washington law, an equine activity sponsor or and equine professional shall not be liable for an injury to or death of a participant engaged in an equine activity. RCWA 4.24.530
Parent/Guardian Signature*

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Date

MonthDayYear
Date
Printed Name of Parent/Guardian
Should be Empty:

WORKSHOP REGISTRATION - YOUTH

EMERGENCY MEDICAL TREATMENT

Consent Plan

PHOTO RELEASE

WAIVER OF LIABILITY