Please indicate below the name and address where bills should be sent if different from the primary contact listed.)
Participant Health & Goal Information
Please update the participant's characteristics, needs and goals in the categories below. If there have been no changes, leave the field blank.
Authorizations and Signatures
(to be invoked in the event that your Emergency Contact cannot be reached.)
If you choose non-consent for emergency medical treatment/aid in the event of illness or injury while on the property of the agency, please request a Non-Consent Form, which requires notarization.
High Hopes Therapeutic Riding, Inc. 1) to use my child’s photograph or image in its print, online and video publications; 2) release High Hopes Therapeutic Riding, 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 3) 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(my child).
(Name) would like to participate in the High Hopes
Therapeutic Riding 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 High Hopes Therapeutic Riding, 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.