Pony Hugs Application
Application for a home pony visit for your child. To qualify, applicants MUST have a child facing medical adversity. Mason's Toy Box Foundation will review all applications and contact applicants with additional questions if needed for approval. Pony Partners will contact families to schedule the visit.
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Email *
Parent/Legal Guardian First and Last Name *
How did you hear about our Pony Hugs Program? *
Parent/Legal Guardian Contact Number (include area code) *
Physical Address for pony visit (include city, state, zip) *
Qualifying Child's First and Last Name *
Qualifying Child's Date of Birth *
Qualifying Child's Diagnosis *
What hospital is your child treated at? *
Hospital Social Workers First and Last Name? *
Is there a specific date you are requesting for a pony visit (ie. birthday party for the child, coming home from the hospital celebration, etc)? If so, please indicate the date and time preferred below. *
Pony Partners and Mason's Toy Box Foundation are non profit organizations which rely on fiscal support to provide families with blessings like home pony visits. lf your child already has a community of support and you choose to share photos to social media, please consider helping spread the word for fiscal support to help continue these efforts. You can do so by encouraging your network to make a contribution to the organizations and liking our social media page. To tag us just use the @ symbol and start typing the organization's name. Please initial below to indicate you have read and understand. *
Pony Partners Waiver & Release Form, the undersigned have read and understand, and freely and voluntarily enter into this Release and Hold Harmless Agreement with PONY PARTNERS and property owner Patricia Fountain. 1. Participant understands that there are risks inherent in dealing with horses and ponies (equine activity). For example, Participant understands that some of the inherent risks include: a. The propensity of an equine to behave in ways that may result in injury, death, or loss to persons on or around the equine; 
b. The unpredictability of an equine’s reaction to sounds, sudden movements, unfamiliar objects, persons, or other animals; 
c. That there may be hazards, including, but not limited to, surface or subsurface conditions; 
d. The possibility of a collision with another equine, another animal, a person, or an object;
e. The potential of an equine activity Participant to act in a negligent manner that may contribute to injury, death, or loss to the person of the Participant or to other persons, including, but not limited to, failing to maintain control over an equine or failing to act within the ability of the Participant. 2. With full understanding of the inherent risks involved in equine activity, some of which have been described in Paragraph 1 above, Participant agrees to wave, release and hold harmless Patricia Fountain from all tort and civil liability arising from or related to participation in any equine activity. This agreement to waive, release and hold harmless includes not only Patricia Fountain but their employees, agents, board members and independent contractors whether they be trainers, veterinary personnel, farrier’s equine care providers, maintenance personnel and the like. 3. Participant further understands the examples of the equine activity taking place on or with an equine, including, but not limited to: a. Riding, mounting, walking, boarding, feeding, grooming, competitions, trail riding, and the like; 
b. Teaching, instructing, and evaluation, both the rider and the equine; 
c. Routine care and feeding of the equine (Boarding), including veterinary and farrier; 
d. Traveling, loading and unloading of equines; e. Use of horse barn, paddock, trails or horse ring in any capacity 4. This Voluntary Waiver Agreement is made and entered into in the State of Virginia and shall be enforced and interpreted under the courts and laws of the State of Virginia. 5. By signing this waiver, Participant agrees that Participant has been given sufficient time to read, understand, and ask questions, if any, concerning the nature and scope of this Voluntary Waiver Agreement. 
Parent or Guardian if Participant is a minor: I acknowledge my signature on behalf of any minor children shall render these provisions applicable and binding to such minor child or children as though they were parties to this agreement.I hereby release and agree to hold Pony Partners harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the farm, or that may otherwise arise in any way in connection with any services received from Pony Partners. I understand that this release discharges Pony Partners from any liability or claim that I, my heirs, or any personal representatives may have against the farm with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Pony Partners. This liability waiver and release extends to the farm together with all owners, partners, and employees.Pony Partners often uses photographs of participants in advertising and promoting the program. We will not use photographs that show faces unless we have your express permission.I AGREE to allow photographs of myself and/or my children to be used for promotional purposes for both Pony Partners and Mason's Toy Box Foundation. I DO NOT AGREE to allow photographs of myself and/or my children to be used for promotional purposes. PLEASE INDICATE PERMISSION BELOW (YES or NO) and initial. *
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