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Client Name:
Date of Birth: Age: Weight: Height:
Address: Apartment/Suite:
City: Province: Postal Code:
Phone: (Home) (Work) (Cell)
Parent or Guardian Name(s):
Same as Client (If checked, do not fill out the address section below)
Address: Apartment/Suite:
City: Province: Postal Code:
In case of an emergency, contact: Phone:
or Phone:
LIABILITY RELEASE (PLEASE READ CAREFULLY)
I would like to participate in the Hope Therapeutic Riding program. I acknowledge the risks and potential for risk, of horseback riding. However I feel that the possible benefit to myself/my son/my daughter/my ward are greater than the risk 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 the Hope Therapeutic Riding Society, its Board of Directors, Instructors, Therapists, Aides, Volunteers and/or Employees for any and all injuries and/or losses that may sustain while participating the riding program.
Signature: ___________________________________________________ Date: _______________
Witness: ____________________________________________________
PHOTO RELEASE
I herby consent to and authorize the use and reproduction by Hope Therapeutic Riding Society of any and all photographs and/or any audio-visual materials taken of me/my son/my daughter/my ward, for promotional printed material, educational activities or for any other use for the benefit of the program.
Signature: ___________________________________________________ Date: _______________
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