Fleet Equestrian Center

Release Form and Information

Fleet Equestrian Center, LLC and If Wishes Were Horses, Inc
Horses for Hearts & Healing Enrollment

Therapeutic Activities with Horses
Participant Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemaleOther
Any information you want to share about "other" for Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Best Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Participant Email
example@example.com
I prefer to be contacted about cancellations by

TextPhone Call
Other important information (allergies etc.)
What Days are you available?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What times are you available on your selected days?
Are you employed?
If employed, What is your job position/profession?
Do you have any of the following ADA Recognized Disabilities, Conditions, or Diagnoses, that would qualify you for the Recreational Therapeutic Activates with Horses Program

AnxietyPhobia, FearPanic AttackDepressionSelective MutismOCDADHDASD- High Functioning or Level 1ASD with ADHD - High Functioning or Level 1Scoliosis/Muscular SkelatalChrone's, Celiac, IBS, GI etcRespiratory, Asthma, OtherSelf Image IssuesEmotional Issues -Self Esteem, Self-Confidence, Isolation, Self HarmGreif and Loss- Recent or ProlongedArthritisMood Disorders - mild to moderate (we are unable to most serve severe mood disorders and schizophrenia)DyslexiaSensory - Auditory, VisualPhysical DisabilityIntegumentary (skin)CardiacNone, but I'd like to participate for my overall wellbeing and therapeutic benefitOther
Specify "Other" or describe specific from list above
What are your goals from this program? (select all that apply)

Relaxation through Guided VisualizationExercise/body movementDe-stressSelf-discoveryBuilding Self ConfidenceSocializing in a non judgmental settingLearning Horse Related SkillsBeing around HorsesBeing out in nature/reconnecting and finding inner peace
Horse Skills You already have

Catching Grooming LeadingLoungingRound Penning and join upNatural HorsemanshipClicker TrainingRiding walkRiding trot/jogRiding canter/lopeNone
Which of these horsemanship levels best describes you. This section lists overall horse skills, even though this program is unmounted -there is no riding. Please pick the level that actually describes you, horses don't lie and your level will show when they meet you.

I am a total beginner - I have never been around horses or have very little experience around themI am between these two levelsI have some experience around horses - I feel comfortable around horses, know how to be safe around them, minimum skills- can lead and groom, I can ride if someone tacks them up for me - comfortable at the walk, maybe some trotI am between these two levelsI have experience around horses - I feel comfortable around horses, know how to be safe around them, I have ridden some (ex. trails, friend's horses, casual riding), minimum skills - can lead, groom, tack, ride comfortably at the walk, trot, maybe canterI am between these two levelsI have a lot of experience around horses - I am comfortable around horses, I can react and respond to horses safely, I can read them to some degree, I have ridden a lot (ex. formal lessons, owned horses, groundwork/lounge, round pen) minimum skills - can lead, groom, tack, ride comfortably at the walk, trot, maybe canter, trail, arenaI am between these two levelsI am an expert horse person - I am very comfortable around horses, I can ride just about anything, I understand horses at a deep level, can read them/their body language, have trained horses or helped to train them (young, unbroken, problem horses) I can catch, groom, tack, lead, lounge, round pen, and ride with no help or supervision - walk trot canter. I could safely keep my own horses and recognize signs of illness and distress, execute a feeding program, recognize herd dynamics - safe herd placement.
Describe any specifics about your previous experience with horses: what do you want me to know? (Optional)
Guided Visualizations with Horses You’d Like to Explore (select all that apply)

Guided Energetic Clearing Visualization for youHeart Connection Mindfulness Guided VisualzationEnvisioning your Best Health and Self Guided VisualzationGuided Meditation on Twin Heart
Mobility Safety - It must be determined that we can safely serve you, further evaluations, such as a trial session may be needed or required.

I am physically able to be around horses and work with them in a safe capacityI am NOT physically able to be around horses and work with them in a safe capacityI am NOT physically able to work around horses but would like to be on the farm and participate in Guided Visualizations with horses, safely away from them
I am a veteran, active duty service member, or first responder. If you answered yes to this question, please contact me about your options

YesNo
What are you able to pay per session?

Beta Testing $2-20 (you choose your donation)$40 per session (does not apply at this time)I need Tuition assistance
I would be interested in

Beta Testing 2-4 week SessionTherapeutic Program 4 weeks (when it becomes available)
For the Therapeutic Program -If you need tuition assistance, explain your circumstances (Not active yet, Beta Testing Only)
Participant Terms and Conditions (For Groundwork Sessions and any potential future Riding Sessions). *Session spots must be attended on a regular bases. Anyone missing more than 2 sessions in a row, for any reason besides medical, emergency, or planned travel, will be considered for replacement. (Does not apply to Beta Testing) Missed Sessions Segments must be paid in full, if you do not wish to give up the spot. *Absences- please give at least (three) hours’ notice of any pre-known absence in writing (text, note, email). * A $10 fee applies for any (one) absence that is not notified within (Three) hour advance, and/or not due to medical/emergency absence. Any prepaid money expires after 6 months of not being used. *Weather cancellations are given 1 hour or more before scheduled session segments. Please be aware: We reserve the right to refuse service to anyone, for any reason. Persons exhibiting disruptive or inappropriate behavior will be asked to leave the premises/program. *Persons who cannot fill a consistent Session spot may call in for available session spots, per time, instead of holding a spot. There is no guarentee of available spots.

“UNDER SOUTH CAROLINA LAW, AN EQUINE ACTIVITY SPONSOR OR EQUINE PROFESSIONAL IS NOT LIABLE FOR THE INJURY TO OR THE DEATH OF A PARTICIPANT IN AN EQUINE ACTIVITY RESULTING FROM THE INHERENT RISK OF EQUINE ACTIVITY, PURSUANT TO ARTICLE 7, CHAPTER 9 OF TITLE 47, CODE OF LAWS OF SOUTH CAROLINA.” *Safety is our desire for all riders/observers/participants, but accidents cannot always be prevented due to the inherent nature of this activity. *Persons entering upon the property assume all risks inherent to the nature of this activity.

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I release and hold harmless Fleet Equestrian Center, LLC, If Wishes Were Horses, Inc, all board members, associates and instructors: Margaret and Bryan Fleet & any Instructors, Assistant or Junior Instructors from any injuries, accidents, and death that may occur due to the nature of this activity.

I am fully responsible for all visitors and family members that I bring onto the premises. Any injury to visiting persons or of property is waived on the same terms as the conditions set above.
I would like to participate in the Recreational Therapeutic Activities with Horses Program, please acknowledge both:

I have read & understand the Equine Liability Immunity Act, as it relates to equine participants and observers.I have read the above terms and conditions of this program and agree to them
***Disclaimer***This program are therapeutic and recreational in nature and is not meant to take the place of any kind of medical treatment, psychological treatment, medication, or any other doctor recommended treatment or therapy. We do not offer any medical or psychological therapy, treatment, or advice of any kind. This is a recreational service only. Any guided visualizations are for entertainment purposes only; with the goal of relaxation, inner peace, and stress relief in conjunction to building a stronger connection with horses. Please follow any and all medical advice given to you by your Doctors and Medical Team. Suitability for the program will be determined by our ability to SAFELY serve you and space in each program session is limited. ***We reserve the right to refuse service to anyone, for any reason, at any time.***

I agreeI disagree
If at any time it is determined that your safety as a participant is in question and that you need to be referred to mental health services (making it unsafe for you to participate in this program), you will not be able to continue in the program.

I agreeI disagree
I realize that there is an inherent risk of harm in working with horses in a close manner and that any accidents that occur, are an unavoidable risk of choosing to participate in this activity. I agree to hold harmless Margaret Fleet, Bryan Fleet, Fleet Equestrian Center, LLC, If Wishes Were Horses, Inc, and all volunteers, board members, officers, assistants, instructors, property owners.

I agreeI disagree
Electronic Signature -by typing your name below you are submitting your electronic signature, as acknowledgement of agreement to terms and conditions of this program. It serves as your binding legal signature.
Date

MonthDayYear
Date
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Release Form and Information

Horses for Hearts & Healing Enrollment