Narrow Gate Horse Ranch Release Form

Participant Form
(If you would prefer to complete this form on paper & mail it in, you can download it here.)

Equine Assisted Growth & Development Services and Equine Riding and/or Driving and/or Training Instruction Agreement

NARROW GATE HORSE RANCH
STABLE/OPERATOR NAME, hereinafter known as “THIS STABLE”.

7535 W 00 NS KOKOMO, IN 46901

Location of Address of THIS STABLE

READ CAREFULLY AND COMPLETE ALL SECTIONS BEFORE SIGNING
I am registering:*

1 child2 children3 children

Child 3
A. REGISTRATION OF PARTICIPANT AND AGREEMENT PURPOSE I, the following listed individual, and the parents or legal guardians thereof if a minor, do hereby voluntarily agree to participate in Equine Assisted Growth and Development Services, hereafter known as EAGDS, and/or equine related instruction as a student of this stable, Narrow Gate Horse Ranch, and that I will utilize school horses provided by THIS STABLE, for EAGDS &/or instruction purposes.
1. PARTICIPANT NAME*

First NameLast Name
2. AGE (if under 18)
3. Date of Birth*

MonthDayYear
4. WEIGHT Over 200#*

YesNo
5. HORSE RIDING EXPERIENCE (Check one that applies)*

BEGINNER(under 10 hrs)OVER 10 HRS
6. Does participant have any physical or mental condition(s) that may affect his/her safety and ability to ride a horse? *

YESNO
7. If you marked “YES”, how can we help this participant with his/her special needs?
8. Does the participant have allergies?*

YESNO
If the participant does have allergies, please list them here and include any medication needed/taken (example: EpiPen, inhaler, etc.)*
*Please note: the parent/guardian must provide and administer the medication.
Please attach a picture of the Participant

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Child 2
A. REGISTRATION OF PARTICIPANT AND AGREEMENT PURPOSE I, the following listed individual, and the parents or legal guardians thereof if a minor, do hereby voluntarily agree to participate in Equine Assisted Growth and Development Services, hereafter known as EAGDS, and/or equine related instruction as a student of this stable, Narrow Gate Horse Ranch, and that I will utilize school horses provided by THIS STABLE, for EAGDS &/or instruction purposes.
1. PARTICIPANT NAME*

First NameLast Name
2. AGE (if under 18)
3. Date of Birth*

MonthDayYear
4. WEIGHT Over 200#*

YesNo
5. HORSE RIDING EXPERIENCE (Check one that applies)*

BEGINNER(under 10 hrs)OVER 10 HRS
6. Does participant have any physical or mental condition(s) that may affect his/her safety and ability to ride a horse? *

YESNO
7. If you marked “YES”, how can we help this participant with his/her special needs?
8. Does the participant have allergies?*

YESNO
If the participant does have allergies, please list them here and include any medication needed/taken (example: EpiPen, inhaler, etc.)*
*Please note: the parent/guardian must provide and administer the medication.
Please attach a picture of the Participant

Browse Files

Cancelof

Child 1
A. REGISTRATION OF PARTICIPANT AND AGREEMENT PURPOSE I, the following listed individual, and the parents or legal guardians thereof if a minor, do hereby voluntarily agree to participate in Equine Assisted Growth and Development Services, hereafter known as EAGDS, and/or equine related instruction as a student of this stable, Narrow Gate Horse Ranch, and that I will utilize school horses provided by THIS STABLE, for EAGDS &/or instruction purposes.
1. PARTICIPANT NAME*

First NameLast Name
2. AGE (if under 18)
3. Date of Birth*

MonthDayYear
4. WEIGHT Over 200#*

YesNo
5. HORSE RIDING EXPERIENCE (Check one that applies)*

BEGINNER(under 10 hrs)OVER 10 HRS
6. Does participant have any physical or mental condition(s) that may affect his/her safety and ability to ride a horse? *

YESNO
7. If you marked “YES”, how can we help this participant with his/her special needs?
8. Does the participant have allergies?*

YESNO
If the participant does have allergies, please list them here and include any medication needed/taken (example: EpiPen, inhaler, etc.)*
*Please note: the parent/guardian must provide and administer the medication.
Please attach a picture of the Participant

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Cancelof

Medical & Financial
9. MEDICAL INSURANCE I/WE AGREE THAT:*

Should medical treatment be required, I and/or my medical insurance shall pay for ALL such incurred expenses.
My medical Insurance company is:
My policy # is
I do not carry medical insurance.
10. Annual Income Bracket

$0 - $25,000$25,000 - $50,000$50,000 & up
Please provide a photo of 1 of the following documents: Food stamp card, Medicaid card, HIP, or proof of free & reduced lunches from school.

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Terms & Conditions

(1 of 2)
RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT

ln consideration of participating in equestrian activities, and for other good and valuable consideration, I hereby agree to release and discharge from liability arising from negligence Narrow Gate Horse Ranch and its owners, directors, officers employees, agents, volunteers, participants, and all other persons or entities acting for them (hereinafter collectively referred to as "Rcleasees"), on behalf of myself and my children, parents, heirs, assigns, personal representative and estate, and also agree as follows:
1. I acknowledge that equestrian activities involve known and unanticipated risks which could result in physical or emotional injury. paralysis or permanent disability, death, and property damage. Risks include, but are not limited to, death. paralysis or serious injury as a result of falls while riding horses; broken bones, bruises and other bodily injuries caused by contact with horses, such as being bitten by, kicked by or stepped on by horses; medical conditions resulting from physical activity; and damaged clothing or other property. I understand such risks simply cannot be eliminated, despite the use of safety equipment, without jeopardizing the essential qualities of the activity.
2. I expressly accept and assume all of the risks inherent in this activity or that might have been caused by the negligence of the Releasees. My participation in this activity is purely voluntary and I elect to participate despite the risks. In addition, if at any time I believe that event conditions are unsafe or that I am unable to participate due to physical or medical conditions, then I will immediately discontinue participation.
3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Releasees from any and all claims, demands, or causes of action which are in any way connected with my participation in this activity, or my use of their equipment or facilities, arising from negligence. This release does not apply to claims arising from intentional conduct. Should Releasees or anyone acting on their behalf be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.
4. I represent that l have adequate insurance to cover any injury or damage I may suffer or cause while participating in this activity, or else I agree to bear the costs of such injury or damage myself. I further represent that I have no medical or physical condition which could interfere with my safety in this activity, or else I am willing to assume - and bear the costs of - all risks that may be created, directly or indirectly, by any such condition.
5. In the event that I file a lawsuit, l agree to do so solely in the state where Releasees' facility is located, and I further agree that the substantive law of that state shall apply.
6. I agree that all enrolled students are required to wear a helmet in class.
7. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.
By signing this document, I agree that if I am hurt or my property is damaged during my participation in this activity, then I may be found by a court of law to have waived my right to maintain a lawsuit against the parties being released on the basis of any claim for negligence.

I have had sufficient time to read this entire document and, should I choose to do so, consult with legal counsel prior to signing. Also, I understand that this activity might not be made available to me or that the cost to engage in this activity would be significantly greater if I were to choose not to sign this release, and agree that the opportunity to participate at the stated cost in return for the execution of this release is a reasonable bargain. I have read and understood this document and I agree to be bound by its terms.
Participant Initials*
Parent or Guardian Initials*
PHOTO RELEASE

I hereby grant to Stable the unrestricted and absolute, perpetual, worldwide right to reproduce, exhibit, display, perform, transmit, broadcast, distribute, modify, create derivatives, and otherwise use the photograph (s) of myself and any minor (s) identified below (the “photograph (s)”) for any purpose whatsoever (“Grant”). (15) I acknowledge that the purposes for which the photograph (s) may be used include, without limitation, Stable publications, videos, books, newsletters, calendars, websites, blogs, and social media. (16) I agree that this Grant includes, without limitation, the right to use the photograph (s) – or any part of it – in combination with, or as a composite of, other matter, including, but not limited to, text, data, images, photographs, illustrations, animation and graphics, video or audio segments of any nature, in any media embodiment, now known or hereafter developed, including, without limitation, print, film, videotape, DVD, broadcast, digital transmission and electronic/online media. (17) I acknowledge that this Grant includes the right to use the name of the minor (s) identified below, whether in original or modified form, or a fictitious name, in connection with the photograph (s). (18) I hereby voluntarily release and forever discharge – on my behalf and on behalf of the minor (s) identified below – Stable from any and all claims, demands, or causes of action for libel, defamation, invasion of privacy or right of publicity, infringement of copyright, or violation of any other right arising out of or relating to any utilization of the photograph (s) or the name of the minor (s) identified below. Such claims, demands, and causes of actions include, without limitation, inadvertent errors, such as blurring, distortion, or alteration, or based upon any decision not to make use of the photograph (s). (19) I understand that Stable and its licenses and assigns are relying on my consent to use the photograph (s) with respect to the promotion of various services or products. I acknowledge that neither myself nor any minor (s) identified below shall receive compensation with respect to any matter referred to in this Photo Release. All images – electronic or non- electronic negatives, positives, and prints – are owned by Stable. Stable is free to assign and license any and all of the rights granted in this Photo Release. (20) I acknowledge that in no event will I have the right to enjoin the distribution or exploitation of the photograph (s). I hereby relinquish any right that I may have to examine or approve the completed product (s) or advertising copy or printed matter that may be used by Stable or its licensees or assigns.
Participant Initials*
Parent or Guardian Initials*

Participant Form

Child 3

Child 2

Child 1

Medical & Financial

Terms & Conditions

Signatures & Contact Info