Horses with Client Intake Form

Name

First NameLast Name

Cell Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Would you like to be added to our email newsletters to receive updates on services and well-being events? We do not share your contact information and the newsletter is typically only sent 1-2 times per month.

YesNo

Emergency contact (name/number)

How did you hear about this event?

Have you ever had a Reiki session before?

YesNo

If yes, when was your last session?

Number of previous sessions:

Do you have a particular area of concern?

Are you sensitive to touch?

IMPORTANT: PLEASE READ THE FOLLOWING LEGAL DOCUMENT CAREFULLY

Waiver and Release from Liability Susanna Farms LLC and Live Life LLC

Live Life LLC

I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

Susanna Farms, LLC

Susanna Farms provides equine activities including riding lessons, equine-assisted activities, special events, and other farm related activities.

I, (adult or minor child) HEREBY WAIVE AND RELEASE, indemnify, hold harmless and forever discharge Susanna Fars and its agents, employees, officers, directors, affiliates, successors and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether know or unknown, in law or equity, that I or Child ever had or may have arising from or in any way related to my/child’s participation in any events or activities conducted by, on the premises of, or for the benefit of, Susanna Farms LLC.

I understand that the activities that I/children will participate in and that I/children will see are inherently dangerous and may cause serious or grievous injuries, including bodily injury, damage to personal property and/or death. I/children will be in direct contact with animals that include but are not limited to: horses, donkeys, goats, pigs, chickens, etc. and other animals that may not be listed. I understand that, as with most animals, they may react in an unpredictable way to sounds, sudden movements, people, or other animals that could result in injuries to people. On behalf of myself, said children, my heirs, assigns and next of kin, I/children waive all claims for damages, injuries and death sustained to me/children or property, that I/children may have against the aforementioned released party to such activity.

By this waiver, I/children, assume any risk, and take full responsibility and waive any claims of personal injury or death or damage to personal property with Susanna Farms LLC including but not limited to visiting the farm, observing or interacting with the animals, horseback riding and activities with equines, using the facility and its equipment in any manner, form or fashion, and practicing and/or engaging in other related activities including the initiating of prohibited contact with the animals on and off the premises and disobeying any Farm regulations both posted and unposted. It is a condition of participation that clients/visitors observe all warning signs, do not venture into adjacent buildings or into off limit areas.

This WAIVER AND RELEASE contains the entire agreement between parties and supersedes any prior written or oral agreements between them concerning the subject matter of this WAIVER AND RELEASE. The provisions of the WAIVER AND RELEASE may be waived, altered, amended or repealed, in whole or in part, only upon the prior written consent of all parties. The provision of this WAIVER AND RELEASE will continue in full force and effect even after the termination of the activities conducted by, on the premises of, or for the benefit of Susanna Farms LLC, whether by agreement, by operation of law, or otherwise.

I have read, understand and fully agree to the terms of this WAIVER AND RELEASE.
I understand and confirm that by signing this WAIVER AND RELEASE that I/children have given up considerable future legal rights. I have signed this Agreement freely, voluntarily, under no duress of threat of duress, without inducement, promise or guarantee being communicated to me. My signature is proof of my intention to execute a complete and unconditional WAIVER AND RELEASE of all liability to the full extent of the law. I am 18 year of age or older, and/or legal guardian of children, and mentally competent to enter into this waiver.

I understand that this agreement contains a promise not to sue Susanna Farms, LLC, Live Life LLC or their employees.

I authorize Susanna Farms, LLC and Live Life LLC, to publish photographs taken of myself and/or the minor child or children listed above, and our names and likenesses, for use in the Susanna Farms, LLC’s print, online and video-based marketing materials, as well another Company publications. By checking “Yes”, I acknowledge that participation is voluntary and that neither I, the minor child, or minor children will receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other Company publications. I hereby release Susanna Farms, LLC, its contractors, its employees and any third parties involved in the creation or publication of Company publications, from liability for any claims by me or any third party in connection with my participation or the participation of the minor children listed below.

YesNo

Signature

Date

Privacy Notice:

No information about any client will be discussed or shared (including your email address) with any third party without written consent of the client or parent/guardian if the client is under 18.

www.LiveLifeSpiritual.com

Reiki with Horses Client Information Form