House of Healing Participant Packet
This packet must be completed once by any individual participating in an organized activity on House of Healing property regardless of age. Separate registration forms must be completed for enrollment each session. Workday volunteers do not need to complete this packet but must sign a release waiver.7300 Britton Rd NE El Reno, OK 73036 (405)434-3723 www.house-of-healing.org
Participant Name
*
First Name
Last Name
Participant Email
example@example.com
Participant Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Participant Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
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Month
-
Day
Year
Date
School (if applicable)
Grade (if applicable)
Please Select
K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
N/A
Height and Weight (required for equine sessions only)
Parent/Guardian Name (if participant is a minor)
First Name
Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian Address (if different than participant)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Phone Number 2
Please enter a valid phone number.
Format: (000) 000-0000.
Any participant health conditions we need to be aware of (Seizures, Learning Disabilities, ADHD, Anxiety Disorder, etc):
Is participant on an IEP or 504?
Yes
No
If Yes, describe modifications:
Participant Interests:
Any other information you would like to share with us about the participant or family situation?
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Participant Agreement and Liability Releases
Each of these statements must be accepted by the participant and parent for participation at House of Healing.
Commitment to Confidentiality: I agree to maintain the confidentiality of the members in this program. I agree not to disclose to anyone outside of this program the identity of anyone or anything that was discussed and/or exhibited here by anyone. Confidentiality of participant records maintained by this program are protected by federal law and regulations. House of Healing may not provide information to any person unless: Consent by the participant or legal representative is in writing at end of this form by signature and submission.
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Participant agrees
Parent/Guardian agrees
Staff/Volunteer Transportation Consent: If I choose to be transported by HOH, I agree to indemnify and hold harmless House of Healing, its employees/agents for all claims, liabilities, costs, losses, and expenses incurred as a result of being transported by the program. In the event of injury or medical emergency while being transported, I consent to first aid or other medical treatment. I agree to be financially responsible for such treatment.
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Participant agrees
Parent/Guardian agrees
Authorization To Use Photographs AND/OR AUDIO-VISUAL: I, hereby grant and authorize House of Healing, Incorporated permission to use my likeness in any and all of its publications, use name(s) of individual(s) or other entities, make reference to such, including website entries, public affairs releases, advertisement materials, broadcast public service advertising (PSAs), reproduce, and/or publish photographs and/or video(s) without payment or any other consideration. I, hereby irrevocably authorize House of Healing to edit, alter, copy, exhibit, publish or distribute photograph(s) and/or video(s) for purposes of publicizing House of Healing’s programs or for any other lawful purpose. I understand that this material may be used in various publications, or for other related endeavors. In addition, all rights to inspect or approve the finished product, including written or electronic copy are waived by such party(ies). Additionally, all rights to be waived to royalties or other compensation arising or related to the use of photograph(s) and/or video(s). I, hereby hold harmless and release forever and discharge House of Healing from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other person(s) acting on my behalf or on the behalf of my estate have or may have by reason of this authorization. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization.
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Participant agrees
Parent/Guardian agrees
EQUINE EXPERIENCE RELEASE OF LIABILITY I, as the individual or parent/legal guardian, am aware of the risks and challenges associated with horses and horsemanship including, but not limited to, predictable or unpredictable behavior which could result in damage to property, the animal, or injury or death to the handler and/or rider. With knowledge and disclosure of the above, I hereby give my consent for participation in the equine program, and agree and covenant not to hold House of Healing, Inc. and/or any of their principals, agents, employees or volunteers liable for any actions or inactions resulting in injury or death as a result of said participation in the program. This consent and waiver shall be in full force and effect until revoked by me, in writing.
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Participant agrees
Parent/Guardian agrees
GENERAL RELEASE OF LIABILITYI, as the individual or parent/legal guardian, give my consent for participation in the activities involved in the House of Healing programs, including physical activities on property. I agree and covenant not to hold House of Healing, Inc and/or any of their principals, agents, employees, or volunteers liable for any actions or inactions resulting in injury or death as a result of said participation in the program. This consent and waiver shall be in full force and effect until revoked by me, in writing.
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Participant agrees
Parent/Guardian agrees
When working with others in an open group setting certain ground rules need to be followed. Agreement to follow these ground rules and to support others in following them allows an atmosphere of trust where healing can take place. 1) I agree to attend and be on time for all classes and if I cannot attend I communicate 6 to 24 hours in advance if possible. 2) I agree to respect all members within the group, recognizing that differences may arise with others during classes. 3) I agree not to have any form of tobacco, alcohol or illegal drugs on the premises. 4) I agree to keep medication that I may bring to the program secure and will not under any circumstances give any medication to another member of the group. 5) I agree not to have any type of weapon on the premises. 6) I agree to dress in a manner which is appropriate which includes good hygiene. 7) I agree to refrain from sexual inappropriateness and/or sexual/romantic relations with others. 8) I agree to refrain from actual violence or threats of violence. 9) I agree to respect the confidentiality of all other participants on grounds and not take personal information, stories or names outside of the program. 10) I agree to support others in following the program rules. 11) If I am aware of an infraction of a ground rule, I will discuss it with the person involved and the staff. 12) I agree to handle any complaints I may have by reporting it immediately to the House of Healing CEO or Program Director. 13) All phones, iPods, must be turned off and placed in the secure area provided. 14) No after hour visits to the farm unless permission has been received from the CEO and visit must be supervised.
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Participant agrees
Parent/Guardian agrees
This form has been fully explained to me. I fully understand and agree with its contents. Participant Signature:
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This form has been fully explained to me. I fully understand and agree with its contents. Parent/Guardian Signature:
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Date
*
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Month
-
Day
Year
Date
Submit
Should be Empty: