Hannah’s Horseshoes of Hope

P.O. Box 574

Bonham, TX 75418

Telephone: (903)640-9106

Fax: (903)583-9389

Participant’s Application, Authorization & Release

Name:                                                                                               Gender:  Male:          Female:

                (Last)                                      (First)                                      (MI)

Age:                           Height:   ’        ”     Weight:          lbs.                 DOB:       /     /     

Street Address:                                                                                         

City:                                                       State:         Zip:         -      

Home Phone:  (      )        -                          Work Phone:  (   )        -             Cell Phone:  (   )   -    

Email:                                                   

Employer/School:                                                                                      

Street Address:                                                                                       

City:                                                     State:       Zip:       -              Phone:  (   )   -    

Parent/Legal Guardian:                                                                              Mother       Father        Guardian  

                                                                (Last)                                      (First)                          (MI)

Street Address (if different):                                                                      

City:                                                     State:       Zip:       -    

Home Phone:  (   )    -                        Work Phone:  (   )    -             Cell Phone:  (   )   -    

Email:                                                 

Parent/Legal Guardian:                                                                              Mother       Father       Guardian  

                                                                (Last)                                      (First)                          (MI)

Street Address (if different):                                                                      

City:                                                     State:         Zip:       -    

Home Phone:  (   )    -                        Work Phone:  (   )        -             Cell Phone:  (   )   -    

Email:                                                 

MEDICATION: (include prescriptions, over-the-counter, name, dose and frequency)

PHYSICAL FUNCTION: (i.e.  Mobility skills such as transfers, walking, wheelchair use, driving/bus riding)

PSYCHO/SOCIAL FUNCTION: (i.e. Work/school, including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc.)

GOALS: (i.e. why are you applying for participation?  What would you like to accomplish?)

SPECIAL NEEDS/LIKES/DISLIKES:

PHOTO RELEASE

I  do      do not   

Consent to and authorize the use and reproduction by Hannah’s Horseshoes of Hope of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, and exhibitions or for any other use for the benefit of the program.

Signature:                                                                                                   Date:   /      /    

                              (Client, Parent, or Legal Guardian)

Hannah’s Horseshoes of Hope

P.O. Box 574

Bonham, TX 75418

Telephone: (903)640-9106

Fax: (903)583-9389

Authorization for Emergency Medical Treatment

Physicians Name:                                                           Medical Facility:        

Health Insurance Company:                                             Policy #:            

Allergies to Medications:                                                                            

Current Medications:                                                                                 

In the event of an emergency, contact:

Name:                                       Relation:                                                

Home Phone: (    )       -               Cell Phone: (   )    -                            Work Phone: (   )   -    

Name:                                      Relation:                                              

Home Phone: (   )    -             Cell Phone: (   )    -                            Work Phone: (   )   -    

Name:                                      Relation:                                              

Home Phone: (   )    -             Cell Phone: (   )    -                            Work Phone: (   )   -    

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 Hannah’s Horseshoes of Hope to:

1.           Secure medical treatment and transportation if needed.

2.           Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.

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) named above is unable to be reached.

Signature:                                                   Date:    /     /    

                  (Client, Parent, or Legal Guardian)

Non-Consent Plan

I do not give my consent for 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.  In the event emergency treatment/aid is required, I wish the following procedures to take place:

Signature:                                                   Date:    /  /    

                  (Client, Parent, or Legal Guardian)

Release of Liability

Hannah’s Horseshoes of Hope, its officers, members, employees and agents will not be responsible for any damages to person, animal or property at the Hannah’s Horseshoes of Hope Riding Center nor will they be responsible for any property lost or destroyed.  The undersigned rider/parent/guardian hereby releases Hannah’s Horseshoes of Hope, its officers, members, employees and agents from any and all liability, claims and damages whatsoever (including costs, expenses, and attorney’s fees) that might result from damages, injuries, or losses to their person or property during, or in connection with, or arising out of any show, clinic, event or function, whether or not such damages, injuries, or losses result directly or indirectly from the negligent act or omission of such released parties.

WARNING:  UNDER TEXAS LAW (CHAPTER 87, CIVIL PRACTICE AND REMEDIES CODE), AN EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES.

In exchange for the use of property owned/leased by Hannah’s Horseshoes of Hope and other valuable consideration, I agree that my use of the premises and any animals, facilities, or equipment owned by Hannah’s Horseshoes of Hope is at my own risk.  I further agree to indemnify and hold harmless Hannah’s Horseshoes of Hope, their respective officers, members, employees, and agents from any and all suits, actions, or claims of any type arising from my use of the premises or participation in the equine activity of such use by my guest, whether or not such claims result directly or indirectly from the negligent act or omissions of the indemnified parties or otherwise.

I acknowledge that riding and involvement with horses is a high-risk activity.  I have read this agreement and fully understand its content.

Signature:                                                   Date:      /     /      

                  (Client, Parent, or Legal Guardian)