Rice's Horses & More Outreach Consent Waiver
I _____________________, do acknowledge and understand the
(name of rider if 18 or older, otherwise,parent or guardian name)
risks and potential risks of horseback riding and the handling of horses. However, I feel that the possible benefits to myself/child/ward are greater than the risks assumed. I hereby, intend to be legally bound, for myself, my heirs, and assigns, executors or administrators, waive and release forever all calims for damages against "Rice's Horses & More Outreach" for any and all injuries and/or losses of myself/child/ward may sustainwhile participating in these events.
_________________________; _____________________________
Parent/Legal Guardian Signature. //////////Rider's Name
Date:_____________; Date intend to ride___________________.
Consent plan:
In the event emergency medical aid/treatment is required due to illness or injury during activities or while being on the property of the agency, I authorize the staff of "Rice's Horses & More Outreach" to:
1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
Rider's name:__________________; DOB____________________
Phone #________________. Person to contact in case of
emergency:__________________. Phone #___________________.
Health Insurance Carrier:________________________ Group Id #_____________.
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 listed below is unable to be reached.
Date:_______________; Consent signature:___________________. |
