Clone of Participant Registration

Participant Registration
Volunteer Name:

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
School or Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Photo Release:
to the use and reproduction by Freedom In Strides of any and all photographs and any other audio/visual materials taken for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
Signature of Volunteer/Staff, Parent or Legal Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Health History
Please describe your current health status, particularly regarding the physical/emotional demands of working in an equine-assisted program. address fitness, cardiac, respiratory, bone or joint function, recent hospitalizations/surgeries or lifestyle changes.
Medications - include prescription and over-the-counter, name, dose and frequency:
Allergies:

Background Information:
Have you ever been charged with or convicted of a crime?
Please Explain:
Signature of Volunteer/Staff, Parent or Legal Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Drivers License?
License Number
State
Confidentiality Agreement
I understand that all information (written and verbal) about participants at this PATH Intl. center is confidential and will not be shared with anyone without the expressed written consent of the participant and their parent/guardian in the case of a minor.
Signature of Volunteer/Staff, Parent or Legal Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I understand that the information provided above is accurate to the best of my knowledge. I know of no reason why I should not participate in the center’s program.
Signature of Volunteer/Staff, Parent or Legal Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Authorization for Emergency Medical Treatment Form
Physician's Name

First NameLast Name
Preferred Medical Facility
Health Insurance Company
Policy #
In the event of emergency contact:
Emergency Contact #1 Name

First NameLast Name
Relation
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 Name

First NameLast Name
Relation
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #3 Name

First NameLast Name
Relation
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Choose one of the following:

Consent Plan: This authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedure deemed “life-saving” by the physician. This provision will only be invoked if the person(s) above are unable to be reached.

Non-Consent Plan: This plan says you do not give consent for any emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. Parent or legal guardian will remain on site at all times during equine assisted activities.
Choose one of the above:
In the event of emergency treatment/aid is required, I would like the following procedure to take place. Non-consent Procedure:
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Volunteers Full Name

WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT

for Freedom in Strides
1. In consideration for receiving permission to participate in Freedom in Strides, I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Freedom In Strides, their officers, agents, servants, or employees (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or any of the property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASES, or otherwise, while participating in such activity is being conducted.

2. I am fully aware of the risks involved and hazards connected with this activity, including but not limited to travel risks and/or risks involved in working with animals and farm equipment. I hereby elect to voluntarily participate in said activity with full knowledge that said activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, which may be sustained by me, or any loss or damage to property, owned by me, as a result of being engaged in such an activity, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.

3. Freedom In Strides recommends and encourages the use of ASTM/SEI certified helmets for all persons working with, or working in close contact with, horses and other livestock.

4. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASEES from any loss, liability, damage or costs, including court costs and attorney fees, that they may incur due to my participation in said activity, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise.

5. I understand that Freedom In Strides does not maintain any insurance policy covering any circumstance arising from my participation in this event or any activity associated with or facilitating that participation. As such, I am aware that I should review my personal insurance portfolio.

6. It is my express intent that this Waiver of Liability and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above-named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Texas.

7. I am aware that under Texas law, Chapter 87 of the Civil Practice and Remedies Code, an equine professional is not liable for an injury to or death of a participant in equine activities resulting from the inherent risks of equine activities. I understand the implications of this law regarding my participation in equine activities.

8. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT that I have read the foregoing Waiver of liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, I have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by the same.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name
If participant is under the age of 18, the Parent/Guardian consents to the minor’s participation in the event, consents for Freedom In Strides to seek reasonable and necessary medical treatment for Participants during such event or associated activities, and agrees to be responsible for any cost of such treatment.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Participant Registration

Health History

Background Information:

Confidentiality Agreement

Authorization for Emergency Medical Treatment Form

In the event of emergency contact:

WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT