Emerald Hollow Therapeutic Riding Center, Inc. 235 Run Hill Road, Brewster, MA 02631 (508) 896-0064
Participant’s Name: ____________________________________________ Date of Birth: ___/___/___ Age: _________ School or Institution Presently Attending: __________________________ Teacher’s Name: _______________________ Weight: _______ Height: _______ Disability: ___________________________________________________________________________________ Primary Contact Name: ________________________________________ Relation: ______________________________ Mailing Address: Street __________________________________ City _________________ State _____ Zip _________
Home Phone: ( ) _________________ Cell Phone: ( ) _________________ Email: ________________________
Photo & Publicity Release _______ I hereby consent and authorize _______ I do not consent to, nor do I authorize Emerald Hollow Therapeutic Riding Center, Inc. to use my or my child’s photograph or image in its print, online, and video publications; and release Emerald Hollow Therapeutic Riding Center, Inc., its employees and any outside third parties from all liabilities or claims that I might assert in connection with the above-described activities; and 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 or my child. Date: ______________________ Consent Signature (Client, Parent, or Legal Guardian): _____________________________________________________ Liability Release (Required) ________________________ (name) would like to participate in the Emerald Hollow Therapeutic Riding Center, Inc. Program. 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/my child/my ward are greater than the risk assumed. I hereby, intending to be legally bound for myself, my heirs and assigns, executors, and administrators, waive and release forever all claims for damages against Emerald Hollow Therapeutic Riding Center, Inc., its Board of Directors, Instructors, Therapists, Aides, Volunteers, and/or Employees for any and all injuries and/or losses I/my child/ my ward may sustain while participating in the Program from whatever cause including but not limited to the negligence of these released parties. The undersigned acknowledges that he/she has read this Registration and Release 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.
Date: ______________________ Consent Signature (Client, Parent, or Legal Guardian): _____________________________________________________