FCVA Workshop Registration
This form is intended for participants in group workshops that have been requested to complete this by Flying Changes staff. DO NOT COMPLETE THIS FORM UNTIL REQUESTED.
Date completed
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Month
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Day
Year
Date
Participant
Information
Participant Name
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First Name
Last Name
Date of birth
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Phone Number
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Format: (000) 000-0000.
E-mail
*
example@example.com
Parent/guardian name (under 18yo or in guardianship)
First Name
Last Name
Parent/guardian phone number
Please enter a valid phone number.
Format: (000) 000-0000.
If participant is a minor, please provide the full name of any individuals approved to pick them up from the workshop.
Workshop name or organization you are attending FCVA event with:
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Releases
Liability and Photo/Media
As a client of Flying Changes VA, Inc., further defined and known as FCVA.I acknowledge and understand the risks and potential risks of interacting with animals and animal riding, including but not limited to: (i) the propensity of an animal to behave in dangerous ways, which may result in injury or death to the participant, or damage to property; (ii) the inability to predict an animal's reaction to sound, movements, objects, persons, or other animals; (iii) hazards of surface or subsurface conditions whether known or unknown; (iv) the condition and age of the equipment or tack; Aware of these risks, I feel that the possible benefits to myself my child/my ward are greater than the risk assumed. I hereby intend to be legally bound, for myself, my heirs and assigns, executors or administrators, and waive and release forever all claims for damages against FCVA and its’ employees, instructors, therapists, aides, volunteers, and their respective families, for any and all injuries and/or losses I may sustain while participating in animal-assisted activities and programming of FCVA. I further certify that the foregoing statements and representations are being made by me knowingly, freely, and voluntarily, and I understand that FCVA, is expressly relying upon the foregoing statements and representations in permitting me to participate in animal-assisted activities and programs provided by FCVA.
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I consent and agree to the Flying Changes VA, Inc. Liability Release as stated above.
I do not consent and agree to the Flying Changes VA, Inc. LLC Liability Release as stated above.
As a client of Flying Changes VA, Inc., further defined and known as FCVA.I acknowledge and understand the risks and potential risks of interacting with animals and animal riding, including but not limited to: (i) the propensity of an animal to behave in dangerous ways, which may result in injury or death to the participant, or damage to property; (ii) the inability to predict an animal's reaction to sound, movements, objects, persons, or other animals; (iii) hazards of surface or subsurface conditions whether known or unknown; (iv) the condition and age of the equipment or tack; Aware of these risks, I feel that the possible benefits to myself my child/my ward are greater than the risk assumed. I hereby intend to be legally bound, for myself, my heirs and assigns, executors or administrators, and waive and release forever all claims for damages against FCVA and its’ employees, instructors, therapists, aides, volunteers, and their respective families, for any and all injuries and/or losses I may sustain while participating in animal-assisted activities and programming of FCVA. I further certify that the foregoing statements and representations are being made by me knowingly, freely, and voluntarily, and I understand that FCVA, is expressly relying upon the foregoing statements and representations in permitting me to participate in animal-assisted activities and programs provided by FCVA.
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I consent and agree to the Flying Changes VA, Inc. Liability Release as stated above.
I do not consent and agree to the Flying Changes VA, Inc. Liability Release as stated above.
Photography Release: I consent to and authorize the use and reproduction by Flying Changes VA, Inc., of any and all photographs and any other audiovisual materials taken of me/my child/my ward for promotional material, educational activities, exhibitions, or for any other use for the benefit of Flying Changes VA, Inc. known as FCVA.
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I consent to the above photography release
I do not consent to the above photography release
Photography Release: I consent to and authorize the use and reproduction by Flying Changes VA, Inc., of any and all photographs and any other audiovisual materials taken of me/my child/my ward for promotional material, educational activities, exhibitions, or for any other use for the benefit of Flying Changes VA, Inc. known as FCVA.
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I consent to the above photography release
I do not consent to the above photography release
Authorization for Emergency Medical Treatment
Consent Plan: In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving/giving services, or while being on the property of the agency or boarding facility, I authorize Flying Changes VA, Inc. to: Secure and retain medical transportation if needed and agree that I or my insurance will indemnify Flying Changes VA, Inc. for the costs of such treatment and transportation; and Release client records upon request to the authorized individual or agency involved in the medical emergency treatment. This authorization includes X-ray, hospitalization, medication and any treatment procedure deemed “lifesaving” by the physician. This provision will only be invoked if the person consenting below is non-responsive in a medical emergency.
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I agree to the statement above on behalf of myself or the client as the parent/guardian of the client.
I do not agree to the statement above on behalf of myself or the client as the parent/guardian of the client.
Consent Plan: In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving/giving services, or while being on the property of the agency or boarding facility, I authorize Flying Changes VA, Inc. to: Secure and retain medical transportation if needed and agree that I or my insurance will indemnify Flying Changes VA, Inc. for the costs of such treatment and transportation; and Release client records upon request to the authorized individual or agency involved in the medical emergency treatment. This authorization includes X-ray, hospitalization, medication and any treatment procedure deemed “lifesaving” by the physician. This provision will only be invoked if the person consenting below is non-responsive in a medical emergency.
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I agree to the statement above on behalf of myself or the client as the parent/guardian of the client.
I do not agree to the statement above on behalf of myself or the client as the parent/guardian of the client.
In the event of an emergency, please contact:
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First Name
Last Name
Emergency Contact phone number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please list any medical, environmental (bees, asthma) or food allergies of the participant.
Primary Care Physician's name
Preferred Medical facility
Barn Rules
We are excited to have you join the Flying Changes Virginia family. A few things to keep in mind while on property (rules). All participants must wear closed toed shoes. Only go into fields/stall with instructor supervision. If riding a horse, all participants must wear ASTM/SEI helmets. People under the influence of drugs or alcohol are not allowed to work with animals. No smoking or dogs are allowed on property, unless service animals. All children must be supervised. Only feed the animals, by hand or bucket, with supervision. Do not borrow things without permission. Barn and horse visits can occur only during scheduled times. It is strongly suggested that you bring/use sunscreen and consider bug spray, based on your preferences.
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I have read, understood and I/my child, will comply with the barn rules above.
Workshop date:
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Month
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Day
Year
Date
Completed by
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First Name
Last Name
Participant (or parent/guardian) Signature
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Submit
Submit
Should be Empty: