StirrUp Purpose Horsemanship Application

StirrUp Purpose

at Faith Run Farms

60575 Billadeau Rd, Bend OR 97702

541-410-0164
Horsemanship Student Application

Please let us know a little about you! This application must be completed if you are interested in either Therapeutic Horsemanship or Sport Riding services.
Participant Name*

First NameLast Name
Is the Participant a:*

MinorIndependent AdultAdult with Legal guardian
If the Participant is a minor or an adult with a legal guardian, please complete the following information for the participant. If the participant does not have phone or email, please enter parent or legal guardian contact information.
Parent/Guardian Name

First NameLast Name
Participant Date of Birth*

DayMonthYear
Participant Age*
Participant Gender*
Participant Phone Number*
Can you receive texts on this phone?*

YesNo
Participant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Email*
example@example.com
Participant Height (ft.inches)*
Participant Weight (lbs)*
Participant School/Institution/Employer:*
Does the Participant have any of the following on file with their school?*

IEPIFSP504 planNA
Please provide an updated copy

Cancelof
Is the Participant a:*

VeteranActive MilitaryFirst ResponderNone of the above
What is the Participant experience level with horses?*

NoneOne time pony, sleigh or trail rideSome riding lessons/beginnerIntermediate riderAdvanced/Experienced riderOther
Tell us about any physical limitations or conditions we should be aware of while working with the Participant:
Please tell us about any behavioral health, sensory or cognitive conditions we should be aware of while working with the Participant:
Does the Participant have a health diagnosis?*

YesNo
If yes, define:
Tell us about your goals for participating?*
What is your availability for a 1-hour weekly session? (check all that apply)*

Monday morningMonday afternoonMonday eveningTuesday morningTuesday afternoonTuesday eveningWednesday morningWednesday afternoonWednesday eveningThursday morningThursday afternoonThursday eveningFriday morningFriday afternoonSaturday morningSaturday afternoonSunday afternoon
How did you hear about us?*

Current or past participantWebsite/Social MediaCommunity OrganizationOther
I do hereby attest that this information is true, accurate and complete to the best of my knowledge.
Signature of Participant or Legal Guardian of Participant (typed name indicates signature):*
Date*

MonthDayYear
Date
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone:*
Please enter a valid phone number.
Relationship to Student:*
HOLD HARMLESS AGREEMENT/RELEASE AND WAIVER OF LIABILITY
I have chosen to participate in equine-related activities directed by StirrUp Purpose including but not limited to riding, volunteering, teaching, training, ground work, grooming and ranch work (the “Activities”). In consideration for StirrUp Purpose allowing me and/or my family, as applicable, to participate in the Activities, to the fullest extent permitted by law, on behalf of myself or my minor children, I hereby voluntarily acknowledge, agree, and contract as follows:
Activity and Associated Risk: (please check each box)*

I am fully responsible for my own safety and the safety of my minor children at all times. StirrUp Purpose makes no assurance the Activities are safe. It is my responsibility to decide whether the Activities present an unreasonable risk of harm or loss to me or my minor children;I acknowledge and understand that working around horses is an inherently dangerous activity and that I may be exposed to dangers and hazards that may include but are not limited to: animal kicks, bites or falls, inclement weather, heat stroke or exhaustion, equipment failures, insect bites, and the negligence of others;As a consequence of the above-stated risks, I acknowledge and understand I may be seriously hurt, disabled or may die from resulting injuries and my property may become damaged;I agree to comply with all posted barn rules at any StirrUp Purpose facility and with the directives given to me by StirrUp Purpose staff and understand StirrUp Purpose staff reserves the right to dismiss me from the facility if I refuse to comply with StirrUp Purpose rules and directives;I acknowledge and understand that the possession and/or use of drugs or alcohol at any StirrUp Purpose facility is strictly prohibited and that failure to comply with this rule will result in my immediate dismissal from any StirrUp Purpose facility;I hereby acknowledge and agree that my and/or my family's right to enter and remain on StirrUp Purpose property and/or to participate in the Activities shall remain at all times solely in StirrUp Purpose discretion, and that StirrUp Purpose may terminate such right at any time in StirrUp Purpose's sole and absolute discretion;In the event of an emergency, if medical aid/treatment is required due to illness or injury while participating in the services of, or while being on the property of, StirrUp Purpose, I authorize StirrUp Purpose to secure and retain medical treatment and/or transportation if needed. This authorization includes any treatment deemed necessary by a treating health care professional and includes, but is not limited to, x-ray, surgery, hospitalization, and medication. In addition, I authorize StirrUp Purpose to release my/my child/my ward's records to any individual involved in medical treatment and/or necessary transportation.
Release of Claims:*

I hearby fully and completely release and hold harmless StirrUp Purpose, and its agents, representatives, employees, contractors and participants (the "Released Parties"), from and against any and all claims, liabilities, costs, expenses, demands, causes of action and damages, including attorneys' fees and costs, arising from or relating to any accident, incident, occurence, injury or loss of any kind to my person or property, including my death or the death of a minor child of mine, resulting, directly or indirectly from: (1) the condition of any StirrUp Purpose property including any buildings or structures; (2) the condition or operation of any machinery or equipment; (3) my participation or my child's participation in the Activities; and (4) the negligent acts or omissions of any Released Party.I hereby further expressly agree to fully indemnify and hold harmless the Released Parties from any suit, action, claim, or other liability, including attorney fees and court costs, for any injury, death, or property damage to any third party relating to or arising from my participation in the Activities or my presence on any StirrUp Purpose property. I hereby further agree that I, my heirs, successors and agents will not make any claim or institute any suit or action at law or in equity against StirrUp Purpose or any Released Party. This Agreement is intended to be as broad and inclusive as is permitted by law.This Agreement will be governed by and construed in accordance with the laws of the State of Oregon, without regard to conflict-of-laws principles. If any provision of this Agreement is determined to be unenforceable for any reason by a court of competent jurisdiction, the remaining covenants and/or provisions shall remain biding and enforceable.
I HEREBY ACKNOWLEDGE AND AGREE THAT I HAVE HAD THE OPPORTUNITY TO CAREFULLY READ, REVIEW, AND CLARIFY ANY QUESTIONS I HAVE PERTAINING TO THIS AGREEMENT BEFORE SIGNING BELOW. I HEREBY ACKNOWLEDGE AND AGREE THAT I HAVE READ THIS RELEASE AND WAIVER AND THAT I UNDERSTAND THE LEGAL AND BINDING EFFECTS OF THIS AGREEMENT, AND EXPRESSLY AGREE TO BE BOUND BY THE TERMS OF THIS AGREEMENT NOW AND AT ALL TIMES IN THE FUTURE. I HEREBY VOLUNTARILY SIGN AND ENTER INTO THIS AGREEMENT ON THE DATE SETH FORTH BELOW.
Signature of Participant or Legal Guardian of Participant (typed name indicates signature):*
Date*

MonthDayYear
Date
CONSENT AND RELEASE FOR USE OF LIKENESS

Photo/Media Release
I give permission for me/my minor child to be photographed or otherwise recorded while participating in activities and I consent to 323 Ranches' use of my/my minor child's likeness through any media for any legitimate purpose by 323 Ranches. I waive all rights of publicity or privacy I may have in my/my minor child's name and likeness.*

YesNo
Signature of Participant or Legal Guardian of Participant (typed name indicates signature):*
Date*

MonthDayYear
Date
Should be Empty:

Horsemanship Student Application

Emergency Contact Information

HOLD HARMLESS AGREEMENT/RELEASE AND WAIVER OF LIABILITY

CONSENT AND RELEASE FOR USE OF LIKENESS