Targeted Program Participant Information

Participant Information

Name

First Name

Last Name

Birthdate

YYYY

Gender

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name

First Name

Last Name

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Participant's Occupation/school grade level

Diagnosis (if any)

Allergies

Seizures

Skin Sensitivity

Ethnicity/Race

When seeking funding, we are frequently asked about the ethnicity of our riders. To help us with this reporting please answer the following optional questions.

Do you consider yourself Hispanic/Latino?

(People of various races may also be of Hispanic ethnicity.)

Yes

Which category best describes your ethnicity/race?

Authorization for Emergency Medical Treatment

Participant's Authorization for Emergency Medical Treatment Form

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 Giant Steps Therapeutic Equestrian Center, Inc. to: • Secure and retain medical treatment and transportation, if needed. • Release records upon request to the authorized individual agency involved in the medical emergency treatment.

Emergency Contact 1 Name (must be local contact)

Emergency Contact 1 Phone

Emergency Contact 1 Relationship

Briefly describe your relationship to the emergency contact that you are providing (e.g. 'Mother', 'Friend', 'Brother').

Emergency Contact 2 Name (must be local contact)

Enter the first and last name of a person we can contact in an emergency.

Emergency Contact 2 Phone

Emergency Contact 2 Relationship

Describe your relationship to this contact (e.g. 'Mother', 'Friend', 'Brother')

Physician's Name

Physician's Phone

Preferred Medical Facility

Health Insurance Center

Health Insurance Policy Number

Consent Plan

This authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedure deemed “lifesaving” by the physician. This provision will only be invoked if the person(s) listed as “emergency contact” is unable to be reached. I agree to pay for or arrange insurance payment for costs and claims Giant Steps Therapeutic Equestrian Center, Inc. incurs or becomes liable to pay for all medical aid, treatment, and procedures arising from any illness or injury covered by this authorization.

Signature for Consent

Date for Consent

YYYY

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, Giant Steps. In the event emergency treatment/aid is required, I wish the following procedures to take place:

Non Consent Plan Details

Signature for Non Consent

Date for Non Consent

YYYY

Policy and Agreements

Photo Release Agreement

The use and reproduction by Giant Steps Therapeutic Equestrian Center, Inc. of any and all photographs and any other audiovisual materials taken of me for promotional printed material, educational activities, social media postings, exhibitions, or for any other use for the benefit of the program.

I consent to and authorize

I do not consent to nor do I authorize

Social Media Agreement

Giant Steps appreciates clients’ enthusiasm in sharing the giant steps our riders are taking as a part of this program. However, we ask that you consult with the Giant Steps Program Director before posting any videos of your sessions online and/or referencing Giant Steps (Facebook, Instagram, Youtube, Twitter, Vine, etc.). For those who do not know our work, some of the therapeutic exercises may be taken out of context. Also, not everyone in our program is open to sharing their personage on social media. I agree to request permission from the Giant Steps Program Director before posting personal videos online of any therapeutic riding sessions that I may capture or be featured in and/or before referencing Giant Steps.

I agree to request permission from the Giant Steps Program Director before posting personal videos online of any therapeutic riding sessions that I may capture or be featured in and/or before referencing Giant Steps.

Signature for Social Media Agreement

Type your name to legally sign

Confidentiality Policy

Confidentiality is defined as “told in secret or private relations; trusted.” Any information in regards to the participants (clients) at Giant Steps must be held in strict confidentiality. It is critical that we respect each individual. Confidentiality is considered one of the most basic responsibilities of our facility. In failure to abide by this policy, the quality of the services we provide may diminish and result in legal ramifications.

I have read and understand Giant Steps’ Policy of Confidentiality and agree to abide by same.

Signature for Confidentiality Agreement

Type your name to legally sign

Riverside Release Form

GIANT STEPS THERAPEUTIC EQUESTRIAN CENTER, INC. AND RIVERSIDE EQUESTRIAN CENTER RELEASE AND INDEMNIFICATION AGREEMENT GENERAL RELEASE – PLEASE READ CAREFULLY THIS CONSENT, RELEASE, AND INDEMNIFICATION AGREEMENT (“Release”) is entered into by the undersigned in favor of Giant Steps Therapeutic Equestrian Center, Inc., Giant Steps’ volunteers, agents, employees, horse lessors, officers, directors, or representatives, Howard Herman, Marcia Herman, Meredith Herman, Ashley Herman, Riverside Equestrian Center, and Burgundy Farms and each of their respective owners, officers, directors, employees and agents (collectively, “Released Parties”). In consideration of my being permitted by Giant Steps Therapeutic Equestrian Center, Inc., Howard Herman, Marcia Herman, Riverside Equestrian Center, and Burgundy Farms or one or more of the owners, employees, officers, directors, and/or agents, to participate in the sport of horseback riding and/or the boarding of horse(s) at Riverside Equestrian Center (herein “Ranch”), and to use the facilities of the Ranch (whether or not such use is on a pay basis), I acknowledge and agree as follows: 1. HAZARDOUS ACTIVITY. I AM AWARE AND UNDERSTAND THAT THE HANDLING, CARE, AND RIDING OF HORSES ARE INHERENTLY HAZARDOUS ACTIVITIES, AND I AM VOLUNTARILY PARTICIPATING IN SUCH ACTIVITIES, AND BEING IN THE VICINITY OF SUCH ACTIVITIES, WITH FULL KNOWLEDGE OF THE DANGERS INVOLVED, AND I ASSUME ALL THE RISK THEREOF. I am aware and understand that horses are powerful, unpredictable, and potentially uncontrollable animals. All horses, even those that are well trained and appear calm and docile, may and will, among other things, buck, rear, kick, bite, run and bolt uncontrollably, without warning, and without apparent cause or in response to external stimuli (such as wind, sound, or movement of people, other horses, other animals (domestic or wild), motor vehicles, bicycles, machinery, doors, or other inanimate objects) that may induce fear, panic, anger or reflex actions in the horse. I am aware and understand that serious permanent bodily injury and disability or death of myself, or others within the vicinity of horses, may result from the handling, care or riding of horses, or being in the vicinity of horses, and that horses and other property belonging to me or others may be, as applicable, killed, injured, or damaged. I HEREBY AGREE TO ACCEPT AND ASSUME ANY AND ALL RISKS OF INJURY (INCLUDING PERMANENT BODILY INJURY AND DISABILITY), ILLNESS, DISEASE OR DEATH TO MYSELF AND TO ALL OTHER PERSONS, AND ALL FINANCIAL LOSSES, INJURY, DAMAGES, DESTRUCTION AND/OR LOSS OF MY PROPERTY, INCLUDING BUT NOT LIMITED TO MY HORSE, AND OTHER PERSONS’ PROPERTY, INCLUDING BUT NOT LIMITED TO THEIR HORSE, ARISING FROM THE HANDLING, CARE, OR RIDING OF HORSES AT THE RANCH BY ME OR OTHER PERSONS, WHETHER CAUSED BY THE NEGLIGENCE OF ANY OF THE RELEASED PARTIES OR OTHERWISE. I FURTHER UNDERSTAND THAT IT IS MY RESPONSIBILITY TO BE INSTRUCTED IN THE PROPER METHODS OF HANDLING AND RIDING A HORSE AND THAT I SHOULD WEAR PROPER SAFETY EQUIPMENT AT ALL TIMES WHILE RIDING HORSES, INCLUDING, WITHOUT LIMITATION, A HELMET AND APPROPRIATE CLOSED-TOE FOOTWEAR AS SUITABLE TO THE RIDER’S PROGRAM. 2. CONDITIONS AT THE RANCH. I am aware and understand that in the ordinary course of business, motor vehicles (with or without horse trailers) and bicycles continuously enter and exit the Ranch property in close proximity to the areas, and in the same areas, in which horses are kept, groomed, and ridden. Furthermore, tractors and other machinery are used on a daily basis in the operation, maintenance, and repair of the Ranch. People are working, walking, running, riding, handling, lunging and/or “turning out” horses. Dogs bark, flags and other objects wave, and other activities, conditions, and distractions occur at the Ranch, all on a daily basis, and in close proximity to horses. Such items, activities, conditions, and objects may cause horses to react in an unpredictable and dangerous manner without warning. I ACCEPT AND ASSUME ANY AND ALL RISK OF INJURY, DISABILITY, DEATH, DAMAGE, AND LOSS 2 THAT MAY RESULT TO ME OR ANY OTHER PERSON AND/OR TO MY HORSE OR PROPERTY AND TO OTHER PERSON’S HORSE OR OTHER PROPERTY, FROM ANY SUCH REACTION OF MY OR ANY OTHER HORSE. I am aware and understand that the Giant Steps riding ring is only partially enclosed, and that rain or runoff may enter the rings causing the riding surface to become slippery. The slippery nature of the riding surface may not be apparent upon visual inspection. I am also aware and understand that the rings, roads, and other grounds and fields at the Ranch may at any time be wet, icy, slippery, rutted, eroded, or rocky, or contain holes. I HEREBY ACCEPT AND ASSUME ANY AND ALL RISK OF INJURY, DISABILITY, DEATH, DAMAGE AND LOSS TO MYSELF AND TO ANY OTHER PERSON, AND TO MY HORSE OR PROPERTY, AND TO ANY OTHER PERSON’S HORSE AND/OR PROPERTY WHETHER OR NOT SUCH HORSES OR PROPERTY ARE UNDER MY CONTROL, AS IS CAUSED BY OR RESULTING FROM THE CONDITIONS OF THE RIDING SURFACE OF THE RIDING RING, GROUNDS, AND FIELDS AT THE RANCH AND RIDING, TRAINING, OR EXERCISING HORSES IN SUCH RINGS, GROUNDS, OR FIELDS, WHETHER CAUSED BY THE NEGLIGENCE OF ANY OF THE RELEASED PARTIES OR OTHERWISE. 3. PERSONAL PROPERTY. I agree that if I bring any personal property to the Ranch, and if I store or leave any personal property at the Ranch (including any personal property left in any tack room or barn) I will do so at my own risk and none of the Released Parties shall have any liability in the event of the loss, damage, unauthorized use by any person including but not limited to a Released Party or theft of any such personal property. 4. AGREEMENT NOT TO SUE. I HEREBY AGREE THAT I, MY HEIRS, DISTRIBUTEES, GUARDIANS, LEGAL REPRESENTATIVES, AND ASSIGNS WILL NOT MAKE A CLAIM AGAINST, SUE, DEMAND COMPENSATION OR INDEMNITY FROM, OR ATTACH ANY OF THE PROPERTY OR ASSETS OF, THE RELEASED PARTIES, and each of them, for any loss or damage arising or resulting from any bodily injury, disability, illness, disease, death, financial loss, property loss, damage or destruction, or other harm of whatever nature, whether foreseen or unforeseen, that may be sustained or suffered by me or any other person as a direct or indirect consequence of my participation, or the participation of any other person, in the handling, care, or riding of horses, or the use of the facilities at the Ranch, or the transportation of my horse, or any other horse, for veterinary care, or the administration of any aid or veterinary care to any such horses, or failure to arrange for any such transportation, aid, or care, whether caused by the negligence of any of the Released Parties or otherwise. 5. RELEASE. On behalf of myself, my heirs, distributees, guardians, legal representatives and assigns, I HEREBY RELEASE AND FOREVER DISCHARGE THE RELEASED PARTIES, AND EACH OF THEM, FROM ALL CLAIMS, ACTIONS, DEMANDS, RIGHTS, CAUSES OF ACTION AND LIABILITIES, EITHER IN LAW OR IN EQUITY, based on any bodily injury, disability, illness, disease, death, financial loss, property loss, damage, or destruction, or other harm of whatever nature, whether foreseen or unforeseen, that may be sustained or suffered by me or by any other person as a direct or indirect consequence of my participation in the handling, care, or riding of horses, or the use of the facilities of the Ranch, or the transportation of my horse, or any other horse, for veterinary care, or the administration of any aid or veterinary care to any such horses, or failure to arrange for any such transportation, aid, or care, whether caused by the negligence of any of the Released Parties or otherwise; provided that nothing in this Section 5 shall be deemed to release any Released Party from liability arising from: (a) his own willful injury of me or any other person or any property, (b) his own fraud, or (c) his own violation of any law. 6. INDEMNIFICATION. I AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS EACH OF THE RELEASED PARTIES from and against any and all claims, suits, demands, liabilities, damages, losses, costs and expenses (including, but not limited to, attorneys fees) arising from or in connection with the injury, illness or death of myself or any person whom I bring or invite to the Ranch, or otherwise permit to be in the vicinity of any horse of mine or in my possession or under my control, including, but not limited to, the damage, destruction, or loss of any of my or any person’s property including, but not limited to horses. 3 7. REPRESENTATIONS AND WARRANTIES. I REPRESENT AND WARRANT THAT: (a) I HAVE READ THIS RELEASE CAREFULLY, AND I FULLY UNDERSTAND ALL OF ITS TERMS AND PROVISIONS; (b) I AM 18 YEARS OF AGE OR OLDER, AND I AM LEGALLY COMPETENT TO ENTER INTO THIS RELEASE; (c) NO PROMISE, INDUCEMENT, OR AGREEMENT HAS BEEN OFFERED OR MADE TO ME IN CONNECTION WITH MY EXECUTION AND DELIVERY OF THIS RELEASE, AND (d) I HAVE KNOWINGLY AND VOLUNTARILY EXECUTED AND DELIVERED THIS RELEASE AT MY OWN RISK AND INITIATIVE, AND MY OWN FREE WILL, WITHOUT RELYING ON ANY STATEMENT OR REPRESENTATION OF ANY RELEASED PARTY. I UNDERSTAND AND ACKNOWLEDGE THAT THIS RELEASE IS A RELEASE OF LEGAL LIABILITY. IN THE EVENT OF ANY LITIGATION, THIS RELEASE MAY BE RAISED AS A DEFENSE AND BAR TO, AND AS A WAIVER AND RELEASE OF, LEGAL RIGHTS THAT MIGHT OTHERWISE BE ASSERTED BY ME OR BY MY HEIRS, DISTRIBUTEES, GUARDIANS, LEGAL REPRESENTATIVES, AND/OR ASSIGNS. 8. SEVERABILITY. If one or more provisions of this Release are held to be unenforceable under applicable law, each unenforceable provision shall be excluded from this release, and the balance of this Release shall be interpreted as if each such unenforceable provision were excluded, and the balance of this Release as so interpreted shall be enforceable in accordance with its terms. 9. UNKNOWN CLAIMS WAIVED. I acknowledge that I understand the following statutory language of California Civil Code Section 1542: “A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR.” Having been so apprised, I specifically waive any right I may have under California Civil Code Section 1542 as to unknown or unsuspected claims. 10. COMPLETE AGREEMENT. This Agreement constitutes the entire Agreement among the parties and supersedes any prior agreement or understanding among them. 11. GOVERNING LAW. This Agreement and the rights of the parties shall be governed by and construed in accordance with the laws of the State of California. 12. CONSENT TO ARBITRATION. Should any dispute arise relating to the subject matter of this Agreement, the parties agree to submit the dispute to binding arbitration in Sonoma County, California, pursuant to the rules of the American Arbitration Association. _____________________________________

I agree to the above Riverside Equestrian Center RELEASE AND INDEMNIFICATION AGREEMENT

Targeted Program Participant Information

Thank you for submitting your application.