Liability Release

This form must be completed by staff, volunteers, visitors and riders. For children and youth under 18, a parent or guardian must complete the form.

First Name

Last Name

Email address

Phone

Date of Birth

Address

City

State (2-letter)

Zip Code

Are you registering to volunteer?

Yes

Are you currently a student? Optional

Yes

Is the applicant listed above under legal disability? Optional

Yes

Adult/Guardian Information

If the person listed above in Section 1 is under the age of eighteen (18) or under legal disability, the adult/guardian must complete this section.

First Name

Last Name

Relationship to Above

Phone Number

Emergency Contact

Check the box if the Parent/Guardian is an emergency contact for person noted previously

Address

City

State (2-letter)

Zip Code

Emergency Contact Information

All fields optional

In case of an emergency medical situation while at Roxy's Ranch Haven, or while participating in a program of Roxy's Ranch Haven, please complete the following information.

Primary Emergency Contact

First Name

Last Name

Relationship to Above

Phone Number

Secondary Emergency Contact

First Name

Last Name

Relationship to Above

Phone Number

Primary Care Physician Information

PCP First Name

PCP Last Name

PCP Phone Number

Preferred Medical Facility/Hospital

Information for Emergency Medical Providers

Roxy's Ranch Haven's Emergency Medical Policy

In the event emergency medical aid/treatment is required, Roxy's Ranch Haven Therapeutic Riding Resources, Inc. will:

Contact 911, state the nature of the emergency and request that an ambulance be sent to the scene of the occurrence;
Contact the person(s) listed above in the priority listed; and
Provide the information listed above to emergency medical providers.

In case of an emergency medical situation while at Roxy's Ranch Haven, or while participating in a program of Roxy's Ranch Haven, please complete the following information.

Photo & Media Consent

Roxy's Ranch Haven Therapeutic Riding Resources, Inc. requests that the above-listed Roxy's Ranch Haven participant/volunteer/staff/visitor consent to, and authorize the use and reproduction of any and all photographs and any other audio-visual materials taken of the above listed by Roxy's Ranch Haven for publication in promotion material, educational activities, exhibitions, publications, broadcasts, website and any other use which promotes Roxy's Ranch Haven Therapeutic Riding Resources, Inc. and its programs.

Equine Activity Release, Assumption of Risk and Agreement to Indemnify (putting text in here)

I have read, acknowledge, and accept the following:

Roxy's Ranch Haven Emergency Medical Policy

Photo & Media Consent

Visitor & Volunteer Liability Waiver & Hold Harmless Agreement

Visitor & Volunteer Liability Waiver & Hold Harmless Agreement

Parties to Agreement: This Visitor & Volunteer Liability Waiver and Hold Harmless Agreement is by between the undersigned Participant and Roxy's Ranch Haven (RRH) operating on the premises located at 2420 Magnolia Ave. , owned by R Albin Enterprises, LLC.

I, the undersigned Participant, a visitor or volunteer or his/her parent or legal guardian, hereby acknowledge that I have voluntarily requested to visited the premises (Initials of visitors _____,) or I have voluntarily decided to participate in caring for, feeding, addressing medical needs of, handling, leading, and moving horses, as well as horseback riding, horse and rider training and instruction, and other activities in the close physical proximity of horses at activities or event.

Horse activities are inherently dangerous.
Being a visitor or volunteer at Roxy's Ranch carries with it inherent risks which cannot be eliminated regardless of care taken to avoid injuries.
Risks may include, but are not limited to, scratches, bruises, sprains, broken bones, concussions and broken skull, back and joint injuries, heart attacks, bites, kicks, head butts, or other physical or psychological injuries resulting in pain, suffering, illnesses, disfigurement, disability, paralysis, death or economic loss.
Injuries may arise from participant’s action; the actions, inactions or negligence of another person or persons; actions of activities of horses or other animals; condition of the premises, including terrain and footing, elements of nature; conditions of vehicles; equipment, or tools and other actions, activities or conditions of any kind.

I, the undersigned participant, my heirs and assigns assume all risks of loss or damage or injury, including death, that may occur or be sustained while I am a visitor or volunteer at Roxy's Ranch Haven.

I have read carefully the previous paragraph and I know, understand, and appreciate these and other risks that are inherent in being a visitor and/or volunteer with RRH hereby reaffirm that my participation is voluntary and that I knowingly assume all such risks. ( Initials of visitor or volunteer: _______).

Waiver: In consideration of being permitted to participate in any way at Roxy's Ranch Haven, for myself the undersigned participant, my heirs and assigns, do hereby release, waive, and discharge from liability, and covenant not to sue Roxy's Ranch Haven, its officers, directors, employees, volunteers, agents, heirs, and assigns, and the Owners, their independent contractor, agents, heirs and assigns, from any and all claims, including the negligence or Roxy's Ranch Haven, or the owners, their respective officers, directors, members, managers, employees, independent contractors, volunteers, agents and assigns, resulting in any accident, physical or psychological injuries or illnesses including death, and any property, economic or emotional loss arising from, but not limited to, my participation as a visitor or volunteer at Roxy's Ranch Haven.

Indemnification and Hold Harmless: I, the undersigned participant, my heirs, and assigns agree to indemnify and hold harmless, its officers, directors, employees, independent contractors, volunteers, agents and assigns, from any and all claims, actions, suits, procedures, costs, expenses, damages, and liabilities, including Attorneys’ fees, that may occur as a result of my participation as a visitor or volunteer at each of them. If I need medical treatment, I agree to be financially responsible for any costs, expenses, or fees incurred as a result of such treatment.

Acknowledgement of Understanding: I, the undersigned, have carefully read this Roxy's Ranch Haven Visitor and Volunteer Liability Waiver and Hold Harmless Agreement, fully understand its terms, and understand that I am giving up substantial legal rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily and intend by my signature to be a complete and unconditional release and waiver of all liability to the greatest extent allowed by law. I agree that if any portion of the Agreement is held invalid or unenforceable, I will continue to be bound by remaining terms.

Type in full name for signature (must be over 18) (Required)

I UNDERSTAND THAT, BY SIGNING THIS DOCUMENT, I MAY BE WAIVING AND RELEASING CERTAIN IMPORTANT RIGHTS WHICH I MIGHT HAVE IF I DID NOT SIGN THIS AGREEMENT. I AM SIGNING THIS DOCUMENT VOLUNTARILY AND WITHOUT ANY COERCION.

Participants Under 18

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name