HORSEPOWER Camp Application

Participants First Name

Middle I.

Last Name

Address

Street address

Street Address Line 2

CityState

Zip

Email

example@example.com

Date of Birth

Date

Parent(s)/ Legal Guardian Name

Employer

Work Number

Please enter a valid phone number.

Address

Street Address Line 2

CityState

Zip

Home Phone

Cell

Physicians Name

Medical Facility

Phone

Health Ins. Company

Policy #

Allergies

Medication

Health History (Fitness, Respiratory. bone & Joint function. recent surgery)

Photo Release (Please check)

I DOI DO NOT

Photo Release (please check): I do ( ) or I do not ) Consent to and authorize the use and reproduction by HORSEPOWER Inc. 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

(If Student is under age of 18 years old this must be signed by a legal guardian)

Date

Emergency Treatment Release Form

(Please choose either Consent Plan and Agreement or Non-Consent Plan)

Consent Plan and Agreement:

In the event emergency medical aid/treatment is required due to illness or injury while being on the property of the I authorize HORSEPOWEI Inc. to 1: Secure and retain medical treatment and transportation as needed and 2: records upon request to the authorized individual or agency involved in the medical emergency treatment. This authorization includes, x ray, surgery, hospitalization, medication, and any treatment procedure deemed "life saving" by physician. This provision will only be invoked if the person(s) below is/are unable to be reached.

Initial

Consent Plan and Agreement Signature

(If Student is under age of 18 years old this must be signed by a legal guardian)

Date

Non-Consent Plan:

I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency.

Inital

Parent or legal guardian will remain on site at all times during equine assisted activitiesIn the event emergency treatment/aid is required, I wish the following procedure to take place:

Only answer if you chose Non-Consent Plan

Client's Name

(Client's Name) would like to participate in the HORSEPOWER Inc., program. I acknowledge the risks and potential for risk of Horseback Riding. However, I feel that the possible benefits to me/my son/my daughter/my ward are greater than the risk assumed. I hereby, in tending to be legally bound, for me, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against HORSE POWER Inc., its Board of Directors, instructors, Therapists, Aides, Volunteers and/or Employees for any and all injuries and/or losses I/my son/my daughter/my ward while participating in HORSEPOWER Inc.

Consent Signature

(If Student is under age of 18 years old this must be signed by a legal guardian)

Date

In the event of an emergency, Please contact:

Name

Phone

Relationship

Name

Phone

Relationship

RELEASE OF LIABILITY AND INDEMNITY AGREEMENT

I hereby agree to indemnify and hold harmless and release Horsepower Inc., its officers, members, agents and volunteers from any and all liability for injury, damages or harm that may occur to me, my representatives, heirs, dependents, guests, or to the equine I am using, or to the property owned or used by me. Further, I represent that I understand the hazardous nature of using equines, including pleasure riding, in which injury can occur to equine and rider due to vehicles, natural and man-made obstacles or materials, other equines, dogs, storms, uneven terrain, stress, and other hazards.

I further understand that I am not riding as an employee but as a volunteer and on my own time. I am covered under my personal insurance and not under workers compensation or HORSEPOWER's insurance.

WARNING

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 Definition of inherent risks of equine activities: those dangers or conditions that are an integral part of engaging in an equine activity, including any of the following:

a. The possibility of an equine behaving in ways that may result in injury, harm or death to person(s) on or around them.

b. The unpredictability of an equine's reaction to such things as sounds, sudden movement, unfamiliar objects, person(s), or other animals.

Participant's Name (Please Print)

Participant's Signature

Date

Parent/Guardian's Name (Please Print) Parent/Guardian's Signature If participant underage of 18 yrs old

Date

4537 Walpole Rd. High Point, NC 27265 - phone (336) 931-1424- fax (336)931-1425 - a non-profitorganization-