I certify that the statements made in this application are true and correct and have been given voluntarily. I understand that this information may be disclosed to any party with legal and proper interest, and I release Healing Reins from any liability whatsoever for supplying such information. I understand that I will not be paid for my services as a volunteer.Applicants Signature* Date* Legal Guardian’s Signature Date (The legal guardian of the applicant must sign if the applicant is less than 18 years old.)
Emergency Contacts:First Name* Last Name* Relation* Phone Number* First Name Last Name Relation Phone Number
In the event emergency medical aid treatment is required, due to illness or injury, during the process of receiving services, or while being on the property of the agency, I authorize Healing Reins of Kentucky, Inc. to:
Signature* Date* (If under 18 years of age, parent/guardian signature required.)
I DO give authorization that may include x-ray, surgery, hospitalization, medication, and any treatment procedure deemed “life saving” by the physician. This provision will only be invoked if the emergency contact(s) above is unable to be reached.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. In the event emergency treatment aid is required, I wish the following procedures to take place: Legal Guardian/Participant Signature:* Date (If under 18 years of age, parent/guardian signature required below.)
I DO give authorization that may include x-ray, surgery, hospitalization, medication, and any treatment procedure deemed “life saving” by the physician. This provision will only be invoked if the emergency contact(s) above is unable to be reached.
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.
I acknowledge and understand the inherent risks of equine activities and that horsemanship experiences can result in injury and even death. In consideration for being accepted into the Healing Reins of Kentucky, Inc. (hereinafter “HR”) volunteer program and for the benefits I receive from participating in the program, I, (please print) First Name* Last Name*, hereby consent to assume the risks of myvolunteer participation in the horsemanship programs sponsored by HR.Accordingly, I hereby, intending to be legally bound, for myself, my heirs and assigns, executors, or administrators, waive and forever release, acquit, discharge and hold harmless HR, the owners of the facilities and properties on which HR conducts its horsemanship programs, including but not limited to Blue Moon Stables and Rolling Hills Equestrian Center, and the officers, directors, agents, employees, representatives, therapists, instructors, and volunteers of HR and the facilities and properties on which HR conducts its horsemanship programs, and any other persons associated with HR’s horsemanship program, and the successors and assigns of each of them, from all manner of claims, demands, and damages of every kind and nature whatsoever I may now or in the future have against these parties on account of any losses or personal injuries, physical or mental condition, known or unknown to myself, and the treatment thereof, as a result of, or in any way connected with HR’s horsemanship programs, or growing out of acts of omission or caused by negligence or in any way incidental to HR’s horsemanship programs. KRS 247.401–247.4029 “WARNING - Under Kentucky law, a farm animal activity sponsor, farm animal professional, or other person does not have the duty to eliminate all risks of injury of participation in farm animal activities. There are inherent risks of injury that you voluntarily accept if you participate in farm animal activities."Legal Guardian/Participant Signature* (If under 18 years of age, parent/guardian signature required.)
I, First Name* Last Name* Consent Do not consent to authorize the use and reproduction by Healing Reins of Kentucky, Inc. of any and all photographs, video/audio materials taken of me for the purpose of ongoing studies, educational activities, exhibitions, promotional materials, or for any other use for the benefit of the program.Legal Guardian/Participant Signature* Date* (If under 18 years of age, parent/guardian signature required.)
Do you authorize the use and reproduction by Healing Reins of Kentucky, Inc. of any and all photographs, video/audio materials taken of me for the purpose of ongoing studies, educational activities, exhibitions, promotional materials, or for any other use for the benefit of the program?