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Equine-Assisted Learning Activity
Healing Reigns, PLLC, MINOR
Registration
Client-Participant:______________________________Date
of Birth:________Age:__________
Address:________________________________________________________________________
City/State:___________________________________________________Zip
Code:___________
Home Phone:_______________Cell Phone:_______________ ___ WorkPhone:______________
Emergency#:_____________________Parent/Legal Guardian Name(s):____________________
School Attending:_____________________Grade:______Contact
Person:__________________
Consent and Waiver of Liability:
I, participant/guardian) _______________________________give consent for
(participant)_____________________for and in consideration of the
agreement of Healing Reigns to participate in Healing Reigns Animal
Assisted Activities and do hereby forever release, acquit, discharge and
hold harmless Healing Reigns PLLC., its owners, trustees, agents,
employees, representatives, successors and assigns, for all manner of
claims, demands, and damages of every kind and nature whatsoever, which
the undersigned may now, or in the future, have against Healing Reigns
PLLC, its owners, trustees, agents, employees,representatives, successors
or assigns on account of any personal injuries, physical or mental
condition, known or unknown, to the undersigned and the treatment
therefore as a result of, or in any way growing out of, acts of Healing
Reigns PLLC., its owners, trustees, agents, employees, representatives
successors or assigns, including but not limited to, their negligence or
gross negligence, in rendering services above described or in any way
incidental thereto.
Under Arizona Law, AN
EQUINE ACTIVITY SPONSOR IS NOT LIABLE FOR AN
INJURY TO, OR THE DEATH OF, A PARTICIPANT IN EQUINE ACTIVITIES RESULTING
FROM THE INHERENT RISKS OF EQUINE ACTIVITIES THAT ARE OBVIOUS AND
NECESSARY. CITATION AZ ST S 12-553
Signature of Client/Participant:_______________________________________
Date:_________________
Signature of Parent or Guardian:_____________________________________
Date:________________________
Photo & Media Release
I consent to and authorize the use and reproduction by Healing Reigns PLLC
of
any and all photographs and any other audio-visual materials taken of my
minor
child/guardian child for promotional materials, educational activities,
website or
for any other use for the benefit of the program.
__________________________________________________
Signature of Parent/Guardian
Date
Participant's Name_______________________________________
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