Leadership Participant Form

Leadership Participant Form
First Name
Middle I
Last Name
Address

Street address

Street Address Line 2

CityState

Zip
Home Phone
Cell Phone
Work Phone
Email
example@example.com
Health Ins Company
Policy
Allergies
Medication
Medication

I understand that there is an inherent risk in working outdoors with animals. I understand that the information given above will only be used in the case of an emergency, should hospitalization be required. All information will be kept confidential.I do not have a medical condition that would increase my risk or risk to others when working with horses and the outdoors.
HORSEPOWER Therapeutic Learning Center

4537 Walpole Rd. High Point, NC 27265

Tel (336)931-1424 Fax (336)931-1425

ride@horsepower.org

www.horsepower.org

I understand that the information provided above is accurate to the best of my knowledge. I know no reason why I should not participate in HORSEPOWER Inc.'s program.
Signature

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

MonthDayYear
Date
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.
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 acknowledge the risks and potential for risks of equine activities, however, I feel that the possible benefits to me and the clients with whom I work are greater than the risks assumed. I hereby, intending to be legally bound for myself, my heirs and assigns, executors, or administrators, waive and release forever all claims for damages against Horsepower Inc., its Board of Directors, instructors, therapists, volunteers, and/or employees for any and all injuries and/or losses I may sustain while participating in Horsepower Inc.'s program.
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 agency, I authorize Horsepower Inc. to: Secure and retain medical treatmentand transportation as needed and 2: Release records upon request to the authorized individual or involved in the 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) listed as your emergency contact is/are unable to be reached.
Please check:

I do consentI do NOT consent
Signature

Clear
Signature: (If rider is under age of 18 years old this must be signed by a legal guardian)
Date

MonthDayYear
Date
Emergency Contact Name
Phone
Emergency Contact Name
Phone
HORSEPOWER Therapeutic Learning Center

4537 Walpole Rd. High Point, NC 27265

Tel (336)931-1424 Fax (336)931-1425

ride@horsepower.org

www.horsepower.org
Should be Empty:

Leadership Participant Form

WARNING

RELEASE OF LIABILITY AND INDEMNITY AGREEMENT

CONSENT PLAN AND AGREEMENT