Three Acres, LLC, Participant Application
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First and Last Name *
Date of Birth *
Address (Street, City, State, Zip) *
Home Phone *
Cell Phone *
May we leave a voicemail? *
Email *
In the event of an emergency, who may we contact? Please provide the person's name, phone number, and relationship to you. *
How did you hear about Three Acres, LLC?
Photo Release: Do you consent to and authorize the use and reproduction by Three Acres, LLC of any and all photographs and audio/visual materials taken of me for promotional materials, educational activities, exhibitions, or any other business-related use? *
Liability Release: The above named person would like to participate in Three Acres, LLC program (s). I/my child or guardian fully understand and acknowledge that risks and dangers exist in the arena and working with horses, and my/my child’s participation in such activities may result in my/my child’s injury or illness, including grievous bodily harm. However, I feel the possible benefits to myself/my child are greater than the risks assumed. I hereby, intending to be legally bound for myself/my child, my heirs and assigns, executors or administrators, voluntarily waive, discharge, hold harmless, and release forever all claims for damages against Three Acres, LLC, its Instructors, Volunteers and/or Employees for any and all injuries and/or losses I/my child or guardian may sustain while participating at Three Acres, LLC from whatever cause, including but not limited to the negligence of these related parties. THE UNDERSIGNED ACKNOWLEDGES THAT THEY HAVE READ THIS APPLICATION IN ITS ENTIRETY; THAT THEY UNDERSTAND THE TERMS OF THIS RELEASE AND HAS SIGNED THIS RELEASE VOLUNTARILY AND WITH FULL KNOWLEDGE OF THE EFFECTS THEREOF. *
Three Acres, LLC may collect data and administer applicable measurement inventories in order to monitor the effectiveness of their programs and continue to improve the services that they provide. This data will always be utilized in an anonymous nature. *
WARNING: Under Nebraska 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 sections 25-21,249 to 25-21,253. *
Authorization for Emergency Medical Treatment: 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 Three Acres, LLC 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 emergency medical transport. This authorization includes, but is not limited to x-ray, surgery, hospitalization, medication and any treatment procedure deemed “lifesaving” by the physician. This provision will only be invoked if the emergency contact person listed in this application cannot be reached. *
Authorization for Emergency Medical Treatment, 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. In the event emergency treatment/aid is required, I wish the following procedures to take place (please describe, including all relevant contact information):
Your Signature: By typing your name below, you agree that your electronic signature of this Agreement shall be as valid as an original signature and shall be effective to bind you to this Agreement. Please type your full name below to consent to this agreement. *
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