Brighter Days Camp - Registration Form

I understand that, in the event medical treatment is required, reasonable effort will be made to contact me.  However, if I cannot be reached, I give my permission to the staff of Carolina Caring, Inc. (“Carolina Caring”)or Rising Hope Farms, LLC (“Rising Hope”) or other venues to seek medical treatment and/or initiate emergency medical services for my child.

I hereby release, defend, indemnify and hold harmless Carolina Caring, Rising Hope, and other venues from and against any and all claims, damages or liability arising directly or indirectly from or related to my child’s participation in, or observation of, activities during Brighter Days Camp, including but not limited to risk of exposure to and transmission of COVID-19 and other infectious diseases.

I have read this document and had the opportunity to have my questions answered before signing below. I fully understand the contents, meaning and impact of this authorization and release and agree that is binding on me, my heirs, executors, administrators and assigns.

This Medical Release / Liability Wwaiver must be signed before the camper can prticipate in the Brighter Days Camp.

I, the above-named individual, hereby voluntarily agree to be photographed and/or videotaped and authorize the unrestricted use of my image, voice and/or likeness (“My Image”) by Carolina Caring, Inc. and unlimited affiliates (“Carolina Caring”). I claim no right to compensation for any of same. Carolina Caring will not receive any remuneration for the use or reproduction of My Image.

I understand My Image may be used in various publications and media outlets, including but not limited to Carolina Caring’s internet site and social media, and that My Image may include my Protected Health Information (“PHI”), such as diagnosis or name, and that since it will be in the public domain, it will not be protected by federal privacy standards. I waive the right to inspect or approve the use of My Image for any such purpose and agree Carolina Caring shall have full exclusive ownership of any photographs and/or videos taken pursuant to this authorization.

I hereby release, defend, indemnify and hold harmless the Carolina Caring from and against any claims, damages or liability arising from or related to the use of the above-described material, including but not limited to claims of defamation, invasion of privacy, or rights of publicity or copyright infringement, as well as claims related to reproduction, publication and distribution.

I understand that I am under no obligation to sign this form and that Carolina Caring will not condition treatment, payment, or eligibility for health care benefits on my decision to sign this authorization. I also understand I have the right to revoke this authorization at any time and that Carolina Caring must be notified of my desired revocation in writing to: Clinical Privacy Officer, 3975 Robinson Rd, Newton, NC 28658. I may request a copy of this authorization and ask questions about the use or disclosure of my PHI by calling the Clinical Privacy Officer at 828-466-0466.

I understand while Carolina Caring will not permit the further release of my PHI beyond the foregoing date, it cannot call back any prior use or disclosure of same.

I am 18 years of age or older. I have read this document before signing below, and I fully understand the contents, meaning and impact of this authorization and release and that is binding on me, my heirs, executors, administrators and assigns.

NOTICE: THIS DOCUMENT CONTAINS COVENANTS AFFECTING YOUR LEGAL RIGHTS. BY SIGNING BELOW, YOU ARE RELEASING ANY AND ALL CLAIMS FOR PERSONAL INJURY, DEATH, AND PROPERTY DAMAGE RESULTING FROM YOUR ENTRY UPON THE PROPERTY AND PARTICIPATION IN THE EVENTS LISTED. PLEASE READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.

WARNING:

UNDER NORTH CAROLINA LAW, AN EQUINE ACTIVITY SPONSOR OR EQUINE PROFESSIONAL IS NOT LIABLE FOR ANY INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE ACTIVITIES RESULTING EXCLUSIVELY FROM THE INHERENT RISKS OF EQUINE ACTIVITIES. CHAPTER 99E OF THE NORTH CAROLINA GENERAL STATUES.

In consideration of being allowed to enter into and participate in various “Equine Activities”, as that term is defined in N.C. Gen. Stat. § 99E-1 (2003), including, but not limited to, horseback riding, instruction, therapy and the use of equine animals and/or tack and equipment on the property of Rising Hope Farms, LLC, Gail C. Wartner, and Kurt W. Wartner, (the “Property”), I, the undersigned, for myself, my heirs, executors, administrators, and assigns (collectively, my “Successors”), hereby waive and release any and all claims for damages, for death, personal injury, loss of property or property damage I may have, or that may subsequently accrue to me, or to my Successors, as a result of my participation in Equine Activities. I , the undersigned , discharge and release in advance all persons and/or their respective heirs, successors, and assigns (collectively, the “Sponsors”), and including, but not limited to, Rising Hope Farms, LLC, Gail C. Wartner, and Kurt C. Wartner, from any and all liability arising out of or connected in any way with my participation in the Equine Activities and/or entry upon the Property, even though that liability may arise out of negligence or carelessness on the part of the persons or entities mentioned above.

1. I acknowledge that Equine Activities involves dangerous and potentially deadly activity. My participation in said Equine Activities is voluntary and done at my own risk. I voluntarily assume all risks of loss, damage or injury that may be sustained while participating in the Equine Activities.
2. I affirm that I am physically fit and sufficiently trained to participate in Equine Activities.
3. I consent to the provision of emergency medical services (in the event such services are necessary) by the Sponsors. I understand and agree that medical or other services rendered to me by, or at the instance of, the Sponsors is not an admission of liability to provide or to continue such services., and is not a waiver by any of the persons or entities mentioned above of any right hereunder.
4. I understand that serious accidents occasionally occur during Equine Activities, and that participants in Equine Activities occasionally sustain mortal or serious personal injuries and/or property damage as a consequence thereof.

Knowing the risks of participation in Equine Activities, I nevertheless hereby agree to assume those risks and to the following:

1. Covenant not to sue. I hereby release, waive, discharge, and covenant not to sue the Sponsors, other participants, spectators, and any persons on the Property (the “Releasees”) from liability to the myself and my successors, for any and all loss or damage, and any claim or demands therefore on account of injury to my person or my property or resulting in my death, whether caused by negligence or otherwise, while I am in or upon the Property, and/or participating in, competing, officiating, observing, volunteering, or working in Equine Activities, or otherwise.
2. Indemnification. I hereby agree to indemnify and save and hold harmless the Releasees from any loss, liability, and damage or cost they might incur due to my presence in or on the Property and/or while participating in, competing, officiating, observing, volunteering, or working in Equine Activities, or otherwise.
3. Assumption of Risk. I assume full responsibility for and risk of bodily injury, death, or property damage due to the negligence or the Releasees, or otherwise, while in or on the Property and/or while participating in, competing, officiating, observing, volunteering, or working in Equine Activities, or otherwise.
4. Continuing Waiver and Release. I hereby acknowledge that it is my desire not to be required to execute this Continuing Liability Waiver and Release each time I enter onto the Property or participate in an Equine Activity, as to do so would be both burdensome and repetitive. Therefore, I hereby agree that this Continuing Liability Waiver and Release shall be continuing in nature and that I shall be bound by the terms hereof on each and every occasion that I enter onto the Property and/or participate in any Equine Activity on the Property, until such time as I deliver to Rising Hope Farms, LLC (3774 Bethany Church Rd., Claremont, NC 28610) a written termination of the Continuing Liability Waiver and Release and the same is actually received by Rising Hope Farms, LLC.
5. Infectious Diseases and illness. I hereby acknowledge that I assume full responsibility for any infectious diseases, illness, or viruses that might incur due to my presence in or on the property and/or participating in, competing, officiating, observing, volunteering, or working in Equine Activities or otherwise.

I further agree that the foregoing is intended to be as broad and inclusive as is permitted by the law of the State of North Carolina, and that if any portion of it is held invalid, it is agreed that the balance shall, not withstanding, continue in full force and effect.

Signature instructions: A Participant over the age of eighteen (18) and not otherwise mentally prohibited should complete, sign and date PART A, below, before an adult witness. If the Participant is under the age of eighteen (18) or mentally prohibited from making decision on his/her own behalf, the parent or guardian of the Participant should complete, sign and date PART B, below, before an adult witness.

AGREEMENT AND CONSENT OF PARENT OR GUARDIAN OF MINOR/MENTALLY CHALLENGED PARTICIPANT.

I, as parent or guardian of the named party below, represent to the Sponsors that the facts concerning my child or ward in the Continuing Liability Waiver and Release are true. I hereby give my permission for my child or ward to enter the Property and participate in Equine Activities pursuant to the terms hereof. In consideration of my child or ward being allowed to enter the Property - and participate in Equine Activities, I agree individually and on behalf of my child or ward to the terms of the Continuing Liability Waiver and Release.

By signing hereto I covenant not to sue the Releasees and I agree to indemnify, save and hold the Releasees harmless for from any loss, liability, and damage or cost they might incur due to my child or ward’s presence in or on the Property or in any way participating in, competing, officiating, observing, volunteering, or working in Equine Activities, or otherwise, and whether caused by negligence of the Releasees or otherwise. I have read and understand everything written above and in the Continuing Liability Waiver and Release. I voluntarily sign this Agreement and further agree that no oral representations, statements, or inducements apart from the above written agreement have been made.

Photo Release:
The undersigned hereby grant to Rising Hope Farms Therapeutic Riding
program the permission to take or have taken still and moving photographs and
films, including television pictures of myself during my volunteer or participant
activities with the program and consents and authorizes Rising Hope Farms to use
and reproduce the photographs, films, pictures, and to circulate and publicize the
same by all means including, but not limited to, newspapers, television media,
brochures, pamphlets, instructional materials, books, and clinical materials.
With respect to the foregoing matters, no inducements or promises have
been made to me to secure my signature to this release other than the intention
of Rising Hope Farms Therapeutic Riding Program and its work.