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Step
1
of 3
General Information
Date
*
For which program are you applying?
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Therapeutic Riding (TR)
Equine Assisted Learning (EAL)
Equine Facilitated Mental Health Learning (EFMHL)
Summer Programs and Clinics
Veterans Programs V.E.T.S (Veterans Equine Therapeutic Services)
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Participant’s Name
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Date of Birth
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Age
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Height
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Weight
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Address
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City
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Phone (2)
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Florida
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Indiana
Iowa
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Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
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New Hampshire
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New York
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Parent/Guardian/ Emergency Contact
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Phone
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Address (if different from above)
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Address Line 2
City
— Select state —
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Referral Source
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Phone
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Health History
Diagnosis
Date of onset
Current or past special needs in the following areas (indicate Y/N, if Y please comment)
Yes
No
Please Comment
Describe your abilities or difficulties in the following areas, please include assistance needed and equipment required
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Vision
Hearing
Sensation
Communication
Heart
Breathing
Digestion
Elimination / Bowel / Bladder
Circulation
Emotional / Mental
Behavioral
Pain
Bone / Joint
Muscular
Thinking / Cognitive
Allergies
Medications(please include dosage and frequency)
Describe your abilities or difficulties in the following areas, please include assistance needed and equipment required
Physical Function (mobility)
Psychosocial Function (work/ school grade completed, hobbies and interests, support system companion animals, fears and concerns)
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Read carefully.
*
Accept
This contract includes a surrender of legal rights.
This Agreement is between the Participant(s), who are identified in the signature blocks below,
and the Released Parties, who are FaithfulHearts Equine Learning Center (“FHELC”), a Colorado
nonprofit corporation, located at 1 Zuni Point, Woodland Park, Colorado 80863, its officers,
directors, members, agents, representatives, employees, volunteers, visitors, independent
contractors, successors, assigns, insurance carrier(s), anyone acting on its behalf, and the owners
of any premises on which activities are carried out, including Ute Pass Properties LLC. Reference
to “I,” “me,” or “my” in this Agreement is to each Participant and his or her parent/legal guardian,
if any.
In consideration for receiving permission to participate in Equestrian Activities, I acknowledge and
agree:
1. WARNING: Under Colorado Law, an equine professional is not liable for an injury to or the
death of a participant in equine activities resulting from the inherent risks of equine activities,
pursuant to section 13-21-119, Colorado Revised Statutes.
2. Equestrian Activities and Acknowledgment of Risks.
a. I understand that there are risks associated with participating in Equestrian Activities (whether
observing or actively participating). Equestrian Activities include but are not limited to horse
activities and riding of any kind, handling horses on the ground, and activities incidental to
mounted or unmounted handling of horses, such as grooming, leading, and simply being on
the premises. Reference to horses in this Agreement includes horses, ponies, mules, donkeys,
or hinnies. Equestrian Activities under this Agreement include such activities taking place on
the premises identified above and any other premises where I participate in such activities
with the Releasees.
b. I understand that the risks, including inherent risks, hazards, and dangers (collectively
referred to in this Agreement as “risks”), of Equestrian Activities can cause injury, damage,
death, or other loss to the Participant or others. I understand that these risks include, but are
not limited to:
i. Risks associated with horses: Participating in Equestrian Activities includes significant
risks. Horses are unpredictable in all circumstances. For example, without warning,
horses can kick, strike, bite, rear, bolt, fall down, and react to the environment, sudden
movements, noise, people and other animals or objects (regardless of training, usual past
behavior, or characteristics). Equipment may break; saddles may slip; and other riders
or handlers may not control their animals. The Participant or other participants may
overestimate their ability or fitness to ride or handle horses; be inattentive; lose control
of their horse; misunderstand or misuse equipment.
ii. Equipment risks: Equipment used in an activity may be misused, or may break, fail or
malfunction. I understand that head gear or other safety gear may prevent or lessen
injury, but that use of safety gear is not a guarantee that injury or death will not occur.
Initials
*
(Participant, if age 18 or older) (Parent/Legal Guardian, if applicable)
Read carefully.
*
Accept
iii. Premises risks: The premises includes indoor and outdoor spaces, including indoor and
outdoor riding arenas with obstacles, a round pen, trails, and other equestrian obstacles
that can result in injury when used. Slippery, icy, uneven ground or other dangerous
conditions may exist in and around the premises. Use of indoor or outdoor spaces shared
with other people and animals risks exposure to communicable diseases, including viruses
(such as the virus that causes COVID-19), bacteria, and other pathogens.
iv. Risks present in an outdoor environment: These risks include travel over uneven terrain,
whether on or off trail, including man-made obstacles or hazards; terrain that has been
altered by animals resulting in increased hazards such as holes in the ground into which
a horse or human may step; stinging, venomous and/or disease carrying animals, insects
or microorganisms; poisonous plants; wild or domestic animals and other natural or
man-made hazards. Participants may be subject dangerous and unpredictable weather
changes. Hazards may not be marked or visible. Activities in remote locations may be far
from medical facilities, causing delays in communication, transportation, evacuation and
medical care.
v. Risks of poor judgment and decision making: These risks include the risk that I or
others, including the Released Parties, may misjudge or negligently judge my or others’
capabilities, health or physical condition; misjudge or negligently judge some aspect of
travel, instruction, medical treatment, weather, or terrain; or misjudge or negligently
construct or maintain the premises, trails, or other obstacles for use by participants.
These risks also include the potential that I or others, including the Released Parties, may
act carelessly or recklessly. These risks also include the risks that the Released Parties
knew or should have known that equipment or tack they provided was faulty, and that
the Released Parties failed to make reasonable and prudent efforts to determine my
ability to engage safely in Equestrian Activities and determine my ability to safely manage
the animal provided.
vi. Risks due to personal health: I understand that mental and physical conditions (including
use or abuse of alcohol or any prescription or non-prescription drugs), known or unknown,
can increase the risks associated with Equestrian Activities. I understand that the Released
Parties cannot anticipate or eliminate all risks associated with my mental or physical
condition, and that I must consult with my health care provider before participating in
Equestrian Activities. I understand that FHELC is not a health care provider and does
not have the knowledge of my health condition that I have or my health care provider
has. I represent that, other than as previously disclosed to my health care provider and
to FHELC, I do not have any mental or physical condition or other impairment that may
impair my ability to safely engage in Equestrian Activities.
c. Consequences of risks include my personal injury, my death, and damage to property
including my horse: The risks described above and other risks may result in falling; being
struck by, colliding with or impacting objects, people, horses, or other animals; reacting
to weather conditions or increased exertion; or becoming disoriented. These and other
circumstances may cause heat or cold related conditions; heart or lung complications; broken bones; hospitalization, paralysis or other permanent disability; mental or emotional trauma;
concussions or other head injuries; sunburn or other burns; illnesses (including contracting
animal/insect borne or contagious diseases); infections; cuts or wounds or other injury,
damage, death or loss. These risks also may result in injury or loss of my property, including
my horse(s), car(s), trailer, or other personal property.
Initials
*
(Participant, if age 18 or older) (Parent/Legal Guardian, if applicable)
Read carefully.
*
Accept
3. Assumption of Risk. I expressly assume responsibility for all risks of Equestrian Activities as
described above. Notwithstanding these risks, I voluntarily participate. I agree to abide by
all rules and policies (including COVID-19 policies) established by the Released Parties for
participation. If I am the Parent/Legal Guardian of a minor Participant, I permit him or her to
participate in Equestrian Activities notwithstanding these risks, and I agree to discuss with him
or her the nature of these activities, the risks and any rules.
4. Personal Responsibility. I agree that I must take responsibility for my safety and conduct around
horses. I agree that I must wear headgear meeting ASTM/SEI standards while participating
in Equestrian Activities, and that I must wear other appropriate safety gear and appropriately
protective shoes and clothing while participating in Equestrian Activities. If I use my personal
equipment and safety gear or headgear, I assume full responsibility and I do not rely on the
Released Parties for their selection, fit, or condition. If I use equipment provided by others,
I agree that I have a responsibility to inspect the fit and condition of that equipment, and to
raise any questions or concerns I may have. If I am around or work with a horse provided by
the Released Parties, I agree that I have a responsibility to make known to them the extent
of my ability and prior experience with horses and to raise any questions or concerns I may
have about the appropriateness of the match with a particular horse. If I use my own horse, I
represent that my horse’s manner and physical condition are adequate for me to participate
safely in Equestrian Activities. I am responsible for providing my own protective supplies, such
as masks or disinfectants, to protect against exposure to communicable diseases.
5. Release and Indemnity.
a. I agree to release and not to sue the Released Parties, for any and all claims that I may have
for injury, damage, death, or other loss (including attorney fees and costs) that is in any way
connected with any Participant’s or other participant’s participation in Equestrian Activities.
I understand that I am agreeing to waive all claims I may have against the Released Parties;
agreeing to bind my legal representative, my estate, assigns, subrogors, or anyone acting
on my behalf; and agreeing that neither I nor my legal representative, my estate, assigns,
subrogors or anyone acting on my behalf will make a claim against the Released Parties
related to or as a result of any Participant injury, damage, death or other loss. This agreement
to release and not to sue includes but is not limited to any claim (whether an investigation
or claim made in a court proceeding or elsewhere) for negligence (but not gross negligence
or willful or wanton misconduct), wrongful death (including claims related to response,
assessment, or treatment for emergency medical or other health issues), property damage
(including to any horse I own or for which I am responsible), loss of consortium, breach of
contract, premises liability, and any other claims for liabilities, attorney fees, expenses or
other loss of mine.
Initials
*
(Participant, if age 18 or older) (Parent/Legal Guardian, if applicable)
Read carefully.
*
Accept
b. I agree to defend and indemnify (meaning I agree to protect by reimbursement or payment)
the Released Parties for any and all claims (a) that I or anyone acting on my behalf brings
against them for injury, damage, death, or other loss (including attorney fees and costs)
arising out of or related to my participation in Equestrian Activities; or (b) that a third party
brings against the Released Parties for injury, damage, death, or other loss caused by my
conduct while participating in Equestrian Activities. This agreement to defend and indemnify
includes an agreement to pay any liabilities; attorney fees; associated legal expenses such as
court costs, expert witness fees, and other litigation costs; and any other losses the Released
Parties incur defending such claims. I agree that the Released Parties retain the right to
choose counsel and direct their defense.
6. Other Provisions.
a. This Agreement applies to all of Participants’ present and future participation in Equestrian
Activities.
b. I agree that Colorado law (without regard to its “conflict of laws” rules) governs this Agreement
and any dispute I have with the Released Parties arising out of or related to this Agreement,
contractual or otherwise, and agree that any mediation, suit, or other proceeding must be
filed or entered into only in Teller, Colorado, or the U.S. District Court in Colorado. For any
dispute not settled by informal discussion, I agree to first attempt to resolve the dispute
through mediation before a mutually acceptable Colorado mediator, the fees for which will
be shared equally by the parties. If mediation fails to resolve the dispute, I agree that the
dispute shall be submitted to binding, confidential, and non-appealable arbitration, with any
threshold question of arbitrability to be decided by the arbitrator. Any arbitration award
may be submitted to a court of competent jurisdiction for entry of judgment. The cost and
expenses of the arbitrator shall initially be shared equally by the parties, subject to paragraph
6.e below.
c. This Agreement contains the parties’ entire agreement. No prior promise, understanding,
or agreement, verbal or otherwise, exists between or binds the parties, except as expressly
stated in this Agreement.
d. This Agreement is to be interpreted and enforced to the fullest extent allowed by law. If
any part of it is deemed unenforceable, the rest of it remains in full force and effect and
enforceable.
e. If I make a claim against one or more of the Released Parties for any matter arising out of
or relating to this Agreement, and this matter is submitted to arbitration or any other legal
suit or proceeding, and one or more of the Released Parties is the prevailing party in the
arbitration, suit, action, or other proceeding, then I will be required to and agree to pay the
Released Party or Parties, in addition to all other damages to which they may be entitled,
their costs incurred in conducting the suit, arbitration, or proceeding, including reasonable
attorney fees and all associated legal expenses, such as court costs, expert witness fees, and
other related costs.
Initials
*
(Participant, if age 18 or older) (Parent/Legal Guardian, if applicable)
Read carefully.
*
Accept
7. Medical Care and Expenses. I agree that if I need emergency medical treatment, I or my own
accident/medical insurance company must pay for all associated expenses. I authorize FHELC
to arrange for emergency medical care or transportation for me in the event of an accident or
injury, and to do so even if it is unable to obtain consent from my parent or legal guardian after
reasonable efforts.
8. I have had the opportunity to ask questions about this Agreement and the risks of participating
in Equestrian Activities. I have carefully read, and I understand and voluntarily sign this
Agreement.
A parent (both parents, if there are two) or legal guardian must sign on behalf of a participant under
age 18 or who otherwise has a legal guardian. By signing as Parent/Legal Guardian, I represent
that I am the parent or legal guardian of the Participant first listed below, and that I am signing not
only for that Participant but also for myself as a Participant.
Participant Name
Participant Signature (if age 18 or older)
(Signature Box)
Date Date of Birth
Parent/Legal Guardian Name & Relationship to Minor
Parent/Legal Guardian Signature (signing as Participant and as Parent/Legal Guardian)
Date
Parent/Legal Guardian Name & Relationship to Minor
Parent/Legal Guardian Signature (signing as Participant and as Parent/Legal Guardian)
(Signature Box)
Date
Email
Phone
Participant Address
Address of Parent/Legal Guardian (if different)
Emergency Contact (Name and Phone):
Initials
*
(Participant, if age 18 or older) (Parent/Legal Guardian, if applicable)
Signature
Clear Signature
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