In the event a parent/guardian/primary contact cannot be reached, who should be contacted regarding medical care or other issues?

Please circle all types of sessions you are interested in: Western Bareback Pad Groundwork Only

Payment information:

A scheduled appointment is not simply an hour on a clock—it is a reserved program time that belongs to you. When you reserve a session, that time is held specifically for you and cannot be offered to another participant.

A. Flat Rate Monthly Prepay: 1 hr sessions  $250/mo
B. Flat Rate Monthly Prepay two participants: $330/mo
C. Sessions not reserved but scheduled 24 hrs in advance: $65/hour.
D. Animal Theraputic Services: purpose driven 1 hr session: $65/hr 
E. Animal Theraputic Services: purpose driven group rate: $265/hr
F. Animal Experience: visiting animals and interaction w/animals (must be scheduled 24 hr in advance for before or after lessons): $10/15 mins

G. Mobile Extension Unit: group $265/hr plus mileage (individual $65/hr)

Note: The physician's permission to participate must be completed and on file before sessions begin. Please see The Physician's Statement Form.

Please indicate current or past problems by marking any that apply: If yes to any, please explain.

If yes, attach a copy of program.

This Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted. Physicians release is mandatory for any person with medical/physical conditions or diagnosis.

Publicity Release: I hereby (circle one) DO / DO NOT consent to give permission to Hoof It Forward to use any photographs or audio/visual material for promotion, education, publication or exhibition for the purposes of conveying information and marketing Hoof It Forward Inc,.

Liability Release: I acknowledge the risks and potential for risks of horseback riding and related equine activities including grievous bodily harm. However, I feel that the possible benefits to myself are greater than the risks 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 Hoof It Forward, Inc, Instructors, Therapists, Aides, Volunteers, and/or Employees for any and all injuries and/or losses I may sustain while participating in activities at any Hoof It Forward, events or activities from whatever cause, including but not limited to the negligence of these related parties. The undersigned acknowledges that he/she has read this registration form in its entirety; that he/she understands the terms of this release and has signed this release voluntarily and with full knowledge of the effects thereof.

Acknowledgement and Assumption of Risk I am aware of the dangers and the risks to my person and property involved while participating in: Equine Assisted Services or Other Equine Event Inherent risks of domestic animal activities include, but shall not be limited to: 1. The propensity of a domestic animal to behave in ways i.e., running, bucking, biting, kicking, shying, stumbling, rearing, falling or stepping on, that may result in an injury, harm or death to persons on or around them; 2. The unpredictability of a domestic animal's reaction to such things as sounds, sudden movement and unfamiliar objects, persons, or other animals; 3. Certain hazards such as surface and subsurface conditions; 4. Collisions with other domestic animals or objects; and 5. The potential of a participant to act in a negligent manner that may contribute to injury to the participant or others, such as failing to maintain control over the domestic animal or not acting within such participant's ability.

North Dakota State Statute: NDCC 53-10-01 Definitions. In this chapter, unless the context or subject matter otherwise requires: 1. "Engages in an equine activity" means a person who rides, trains, drives, or is a passenger upon an equine, whether mounted or unmounted, and does not mean a spectator in equine activity or a person who participates in the equine activity but does not not ride, train, drive, or ride as a passenger upon an equine. 2. "Equine" means a horse, pony, mule, donkey, or hinny. 3. "Equine activity" means: a. An equine show, fair, competition, performance, or parade that involves any breed of equine in any equine discipline, including dressage, a hunter and jumper horse show, grand prix jumping, a three-day event, combined training, a rodeo, driving, pulling, cutting, polo, steeple chasing, endurance, trail riding, guided trail rides, pleasure trail riding, wagon and buggy rides, and western games and hunting, b. An equine training or teaching activity; c. Boarding an equine; d. Riding, inspecting, or evaluating an equine belonging to another whether the owner has received some monetary consideration or other thing of value for the use of the equine or is permitting a prospective purchaser of the equine to ride, inspect, or evaluate the equine; and e. A ride, trip, hunt, or other equine activity of any type however informal or impromptu that is sponsored by an equine activity sponsor. 4. "Equine activity sponsor" means an individual, group, club, partnership, corporation, or limited liability company, whether or not the sponsor is operating for profit or nonprofit, which sponsors, organizes, or provides the facility for an equine activity including a pony club, 4-H club, hunt club, riding club, school or college-sponsored class or program, therapeutic riding program, and an operator, instructor, or promoter of an equine facility including but not limited to a stable, clubhouse, pony ride string, fair, or arena at which the activity is held. 5. "Equine professional" means a person engaged for compensation in: a. Instructing a participant or renting to a participant an equine for the purpose of riding, driving, or being a passenger upon an equine; or b. In renting equipment or tack to a participant. 6. "Participant" means any person, whether amateur or professional, who directly engages in an equine activity, whether or not a fee is paid to participate in the equine activity.

NDCC 53-10-02. EQUINE ACTIVITY SPONSOR OR PROFESSIONAL Liability of equine activity sponsor or equine professional limited. 1. Except as provided in subsection 2, an equine activity sponsor or an equine professional is not liable for an injury to or the death of a participant

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engaged in an equine activity, and, except as provided in subsection 2, no participant or participant's representative may maintain an action against or recover from an equine activity sponsor or an equine professional for an injury to or the death of a participant engaged in an equine activity. This chapter does not apply to the horse racing industry as regulated in chapter 53-06.2. 2. Nothing in subsection 1 prevents or limits the liability of an equine activity sponsor or an equine professional: a. If the equine activity sponsor or the equine professional: (1)
Provided the equipment or tack and the equipment or tack caused the injury; or (2) Provided the equine and failed to make reasonable and prudent efforts to determine the ability of the participant to engage safely in the equine activity, to determine the ability of the equine to behave safely with the participant, Page No. 1 and to determine the ability of the participant to safely manage the particular equine; b. If the equine activity sponsor or the equine professional owns, leases, rents, or otherwise is in lawful possession and control of the land or facility upon
which the participant sustained an injury because of the dangerous latent condition which was known to or should have been known to the equine activity sponsor or the equine professional and for which a warning sign has not been conspicuously posted; c. If the equine activity
sponsor or the equine professional commits an act or omission that constitutes willful or blaton disregard for the safety of the participant and that act or omission caused the injury, d.If the equine activity sponsor or the equine professional intentionally injures the participant, e.Under products liability provisions as set forth in products liability laws, or f. Under liability
provisions in chapter 36-11. ________ Initial

We encourage, but do not require, other interactions with the farm animals to promote social and emotional connection, to build lasting relationships. Learning to establish healthy boundaries and respect while building self-esteem promotes endless opportunities for growth and personal development. On the location, Hoof it Forward Leases, buildings, pasture, and corrals for daily use. There is access to the property; however, guests must treat it with respect. I acknowledge that Hoof It Forward is a separate entity. I acknowledge that I must obtain consent to visit any other areas on the property. I acknowledge that Hoof It Forward and the Property owner are NOT RESPSONSIBLE FOR ACCIDENTS, INJURIES, ANY INCIDENTS that could occur with any other animals that live on the property. I am aware of the risks and dangers that can occur with any animal: they can bite, kick, run, step on stumble on, fall, fight at any given time (they have natural born instincts). If I choose to engage with any animal, I agree the risks outweigh the benefits.

I hereby give permission for the applicant as named below, that 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 Hoof It Forward to (1) secure and retain medical treatment and transportation if needed (2) release client records upon request to the authorized individual or agency involved in the medical emergency treatment. YES OR NO

Please list two people who may be contacted in case of emergency.

The purpose of this Code of Ethics is to ensure the success and reputation of Hoof It Forward, Inc through all the staff, volunteers, parents/visitors who represent the program and the participants we serve. It articulates our core values.

Cleanliness and Appropriate Attire: The image you present will represent HIF. A clean, neat appearance will give Hoof It Forward the ability to let Jesus shine through you. Clothing should protect the volunteer, provide comfort, and give a professional appearance. Boots or closed-toed shoes must always be worn when around horses.
You may be the first impression people will have of HIF—let's give them a good one!
(Inappropriate attire: sandals, bare mid-riff or ill-fitting pants, short shorts, offensive/vulgar logos.)

Professional Presentation: Staff, Volunteers, and Participants will use respectful, appropriate language at ALL times— at Sessions, Activities, Events, as well as within the Community and while working at the Facility. Respect and compassion for others should be evident in our conduct at all times. Abusive language, disrespectful comments, sexual harassment, or threatening physical movements will NOT be tolerated. Proper horsemanship will be demonstrated at all times.

Confidentiality: Discussion of our program with the Community is encouraged; however, it is of the utmost importance that the names of participants are never used. Services for all participants are provided with one hundred percent confidentiality. If asked by someone about a specific person, respectfully explain that you cannot say. Always practice the Rules of HIPAA! No photos or social media postings will be made without approval by a Board officer.
"Confidential information" includes, but is not limited to, personally identifiable information such as surnames, telephone numbers, addresses, e-mails, etc. as well as the non-public business records of Hoof It Forward. Medical information about clients and information about their disabilities or special needs must be protected as confidential information. Pertinent information shared between staff/volunteers necessary for various participation needs and safety is the only time information is shared.

Dependability: The success of Hoof It Forward lies in the hands of all Staff, Volunteers, and family. Being dependable and timely for all activities and sessions for which you have committed your time is imperative.

Safety: The safety of all Participants, Volunteers, and Horses should always be our first concern. Many of our procedures and practices have been developed to ensure the safety of all involved. Your full attention, physically and mentally, must be given while involved an equine assisted learning or equine assisted horsemanship session. Your focus in any given situation and your

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ability to follow procedures may well prevent accidents/injuries from occurring. For safety reasons, we do not allow the use of cell phones at any time during sessions or events or any handling of horses. If you must make a call, do it during the break time, which is after all the horses are ready for the next session. 

Observers/guest MUST STAY IN DESIGNATED AREAS ONLY.  For liability issues, no one is allowed to enter the residence area, pens, pastures, or other buildings unless accompanied by Hoof It Forward staff, members, or volunteers.  WE MUST RESPECT THE ORGANIZATION IS LOCATED ON A RESIDENCE.  SAFETY FOR ALL IS THE MAIN FOCUS.  PLEASE RESPECT THE BOUNDARIES AND UNDERSTAND OUR STAFF, MEMBERS, VOLUNTEERS AND RESIDENTS ON THE PROPERTY CANNOT BE LIABLE FOR OBSERVERS, GUESTS, OTHER CHILDREN UNATTENDED DURING LESSON TIMES. NO DRIVING THROUGH RESIDENCE.  PARK IN APPROVED PARKING AREAS ONLY.  SLOW DOWN WHEN DRIVING IN FROM HWY AS LESSONS MAY BE OCCURING AT THAT TIME.   Our staff, members, and volunteers first and formost are accountable to our particpants.  As a PATH INTL member center, we must follow standards. 

Parent/Participant of Hoof It Forward, I understand the Hoof It Forward Code of Ethics and agree to follow it at all times. I choose to represent Hoof It Forward in a manner that is appropriate and respectful, and I agree that I must do no harm to Hoof It Forward or its reputation. I understand that failure to do so will result in loss of my right to participate in any capacity with Hoof It Forward, Inc., I also understand that I am responsible for ensuring that any visitor I bring to the property or events abides by this Code of Ethics.  Thank you for your cooperation and participation!

Cancelation Policy:  If Hoof It Forward cancels a session due to Holiday, illness, weather, or insuffcient staffing, each participant will reschedule for Friday of the same week or the session will extend one week of flat rate to make up for any inconvience.  Paricipants must call 24 hrs in advance and can make up lesson time on Fridays-to be scheduled by participant/guardian with Hoof It Forward.