Client Release and Waiver of Liability

Full Name

First NameLast Name

Parent/Guardian (if under 18)

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact

First NameLast Name

Emergency Contact Relationship

Emergency Contact Phone Number

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THIS IS A VOLUNTARY RELEASE OF LIABILITY. IT IS ALSO A BINDING ASSUMPTION OF RISK AND INDEMNITY CONTRACT.

In consideration of Type a label treatment for myself or my horse(s), I , the undersigned, Type a label , on behalf of myself, my representatives, assigns, executors, and heirs (collectively the "Client"), hereby agree as follows:

Services may include: Physical Therapeutic evaluation, assessment, exercise prescription and education, Therapeutic Massage, Dry needling, cryotherapy, and cupping. I understand that results are not guaranteed. I affirm no promises of efficacy or results made by Alexis Anderson regarding the outcomes or results of treatment.

RELEASE OF LIABILITY AND HOLD HARMLESS

I hereby fully and forever release, waive and discharge&#13;&#10;Alexia Anderson, Ad Astra Eventing, its owners,&#13;&#10;members, employees, agents, representatives, and assigns (collectively the “Releasees’) from&#13;&#10;any and all claims, demands, actions, or causes of action of any kind, including statutory&#13;&#10;remedies, which I may or might have against the Releasees, arising from/or by reason of, any&#13;&#10;and all known and unknown, foreseen or unforeseen, bodily injuries, damage to property, and&#13;&#10;any consequences therefrom, which I may sustain due to Releasees’ negligence.&#13;&#10;&#13;&#10;I shall not bring any demand, claim, legal action against and/or sue the Releasees for any economic or non-economic losses due to bodily injury, death, or property damage as a result of&#13;&#10;the Releasees’ negligence.&#13;&#10;&#13;&#10;I hereby agree to indemnify and hold harmless the Releasees from and against any and all claims, liabilities, loss, damages, demands, actions, causes of action, including attorney’s fees, costs and expenses of any kind, which may be made against them which arise out of the Releasees’ services to my horse(s).&#13;&#10;&#13;&#10;Entire Agreement; Construction; Attorney’s Fees. This contract contains the entire understanding of the parties and may be modified only in writing. The invalidity or unenforceability of any term or provision shall not affect the validity or enforceability of the remainder of the provisions contained herein. This Agreement shall be interpreted and construed by the laws of Colorado. In the event the Releasees retain an attorney to attempt to collect any sums due to them hereunder, to enforce any of their rights under this contract or&#13;&#10;state law, or to defend any action brought against them, in addition to any and all other remedies available to them under the law, they shall be entitled to recover reasonable attorney’s fees and costs from the Participant (if they prevail). I have carefully read this Release and I fully understand its content. I am aware that this is a Release of Liability, a waiver of legal rights and a contract between myself and the Releasees identified above. I sign this Release at my own free will. This Release shall be in full force and effect as of the date of this signature and for any and all future treatment and/or services.

Signature of Rider (Parent or Guardian if under 18 yrs.)

Date