Blue Sky Moments Program

Participant Registration

and Guardian Consent form

Please fill out the participant information below if you are over 18 years old. 

* Legal Parent/Guardian or DFCS Case Manager :

Your child or teen has been invited to participate in our Blue Sky Moments program. We have trained volunteer mentors that have dedicated their time to serving each participant. Your child's mentor will only visit with him/her on-site during Blue Sky Moments scheduled sessions.

Your signature indicates your permission:

1. For your child to participate in the Blue Sky Moments program.

2. For pertinent information regarding your child, including but not limited to: history, challenges, strengths, interests and goals be distributed to the assigned volunteer mentor.

All information listed below is confidential and will only be seen by the Blue Sky Moments Executive Director, Program Director and your child's assigned volunteer mentor.

GENERAL ACTIVITY RELEASE, ASSUMPTION OF RISK and WAIVER OF LIABILITY AGREEMENT

*This document waives important legal rights. Read it carefully before signing.*

I AGREE that I /my child /my ward choose to participate voluntarily in Blue Sky Acres activities as a rider, handler or spectator. I am fully aware and acknowledge that horse sports and Blue Sky Acres activities involve inherent dangerous risks of accident, loss, and serious bodily injury including, but not limited to, broken bones, head injuries, trauma, pain, suffering or death ("Harm"). I fully understand that this release covers, but is not limited to, inherent risks of an equine activity, which mean a danger, or condition that is an integral part of an equine activity, including but not limited to, any of the following:

• The propensity of an equine to behave in ways that may result in injury, death, or loss to persons on or around the equine;
• The unpredictability of an equine's reaction to sounds, sudden movement, unfamiliar objects, persons, or other animals;
• Hazards, including, but not limited to, surface or subsurface conditions;
• A collision with another equine, another animal, a person, or an object;
• The potential of an equine activity participant to act in a negligent manner that may contribute to injury, death, or loss to the person of the participant or to other persons, including but not limited to, failing to maintain control over an equine or failing to act within the ability of the participant.

I AGREE that I /my child/ my ward would like to participate in the Blue Sky Acres program. I acknowledge the risks and potential risks of horse activities in and around a facility where horses are kept and farm machinery operated. However, I feel that the possible benefits to me/ my child/ my ward are greater than the risk assumed. I hereby, intending to be legally bound for myself, my heirs and assigns, executors or administrators waive and release forever all claims for damages against Blue Sky Acres, its Board of Directors, instructors, therapists, aides, volunteers, employees, and affiliated organizations for any and all injuries and/or losses I may sustain while participating in the Blue Sky Acres programs including activities occurring outside of the scope of the program itself, including, but not limited to transportation, caregiving, horse exercising etc. This release includes without limitation the risk of negligent instruction and supervision.

By signing below, I ACKNOWLEDGE that I enter into this release after having read the same, and place my signature hereto of my own free voluntary act and deed.

By signing below, I represent to Blue Sky Acres that I fully understand the contents of this document, that I do not need any further explanation, and I waive any further explanation.

I AGREE to assume all risks of injury, harm, death and property damage that may result to me and/or my child/my ward. I agree to bear any loss myself. I also specifically agree to the GEORGIA LIABILITY LAW regarding equine/farm animal activity liability: Under Georgia Law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in an equine activity resulting from an inherent risk of equine activity, chapter 12, Title 4 of the official code of Georgia annotated.

ACCEPTED BY: (if under the age of 18 years old, there must be a legal guardian signature below):

Both date and signature MUST be completed.

PHOTO RELEASE 

1. Blue Sky Acres to use and reproduce any photograph or image in its print, online and video publications of me/my child/my ward for distribution to the public for promotional printed materials, educational activities or for any other use for the benefit of the program;
2. to release Blue Sky Acres, its employees and any outside parties from all liabilities or claims that I might assert in connection with the above-described activities and
3. to waive any right to inspect, approve or receive compensation for any materials or communications, including photographs, videotapes, DVDs, website images or written materials, incorporating photos/images of me/my child/my ward.

Please sign below confirming your choice:

Authorization of Emergency Medical Treatment

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize Blue Sky Acres to secure and retain medical treatment and transportation if needed and release client records upon request to the authorized individual or agency involved in the medical emergency treatment.

Consent Plan

Signing this gives consent to an x-ray, surgery, hospitalization, medication and any treatment procedure deemed "life saving" by the physician. This provision will only be invoked if the person below is unable to be reached.

Non-Consent Plan

I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services, or while being on the property of Blue Sky Acres.