Some Important Information Before Proceeding

We’re so excited to see you at Horse Camp!!

Please complete the attached paperwork and return it to , mail it to PO Box 591 Kingsburg, CA 93631, or bring COMPLETED paperwork to the first day of camp.

Some important information before proceeding…

1. Attire: Closed toed shoes and helmet. We have helmets riders can borrow, but we advise bringing a helmet if you have one. A bike helmet is fine.

2. Cost: 3 day session: $150.00; 2 day session: 130.00; 1 day session: $65.00

3. Your spot will be help once we receive your $50.00 deposit. The rest of the fee is due 1 week prior to camp. You can pay in full up front if you wish. The deposit is non-refundable.

4. If you have more than one rider attending, please complete all documents for each rider.

5. If you would like, your rider can bring apples or carrots for the horses, they love it!

6. A snack will be served, if your child has any food allergies please let us know ASAP so we can plan accordingly.

7. Camp starts promptly at 8:00am and ends at 12:00pm. Please drop off and pick up your camper promptly. If the week you are signed up for camp is supposed to be extremely hot we will change the time so camp will run from 7:30am-11:30pm. You will be notified of the change if there is one.

8. If you have family or friends interested in camp please pass along our information!

If you have any questions please don’t hesitate to ask! I can be reached at or 559-393-1948

We look forward to working with you!

Kasey Thiesen

SpiritHorse Connections Riding Lessons

GENERAL INFORMATION

Rider Name: ______Date of Birth:___/_____/____

Parent/Legal Guardian (if minor): ______

Phone: (Home) ______(Cell) ______(Work) ______

Address: ______City:______State:____ Zip Code:______

E-Mail:______

Referral Source: ______

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

Applicant’s Name: ______Date of Birth: ____/____/______Phone: (___)______

Applicant’s Address: ______City: ______State:____ Zip Code:______

Medical Facility:______Phone: (______)______

Physician’s Name:______Phone: (______)______

Health Insurance Company:______Policy #:______

Allergies to Medications:______

______

Current Medications: ______

Emergency Contacts:

Name: ______Relation:______Phone: (____)______

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 SpiritHorse Connections Therapeutic Center to:

1. Secure and retain medical treatment and transportation if needed.

2. Release volunteer records upon request to the authorized individual or agency involved in the medical emergency treatment.

*(Please sign the CONSENT PLAN or the NON-CONSENT PLAN on next page)

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

Consent Plan

I DO give authorization that may include x-ray, surgery, hospitalization, medication, and any treatment procedure deemed “life saving” by the physician. This provision will only be invoked if the emergency contact person(s) above is unable to be reached.

Signature: ______Date: ____/_____/______

If under 18 years of age, parent/guardian signature required below.

Signature: ______Date: ____/____/______

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: ______

______

Signature: ______Date: _____/_____/______

If under 18 years of age, parent/guardian signature required below.

Signature: ______Date: ____/_____/______

PHOTO AND VIDEO CONSENT

I, ______consent_____ or do not consent______to authorize the use and reproduction by SpiritHorse Connections Therapeutic Center of any and all photographs, video/audio materials taken of me for the purpose of on-going studies, educational activities, exhibitions, promotional materials or for any other use for the benefit of the program.

Signature: ______Date: _____/______/______

If under 18 years of age, parent/guardian signature required below.

Signature: ______Date: ____/_____/______

SPIRITHORSE CONNECTIONS THERAPEUTIC RIDING CENTER

RELEASE OF LIABILITY

This Release of Liability is made and entered into on this date _____/______/______and for thereafter between SpiritHorse Connections Therapeutic Center and ______(The Participant); and, if Participant is a minor, their Parent or Legal Guardian ______.

In return for use, today and on future dates, of the property, facility and services of SpiritHorse Connections the Participant, his heirs, assigns and legal representatives, hereby expressly agree to the following:

1. It is the responsibility of the Participant to carry full and complete insurance coverage on his/her horse if he/she owns or leases one, personal property, and him/her self.

2. Participant agrees to assume Any And All Risks Involved In Or Arising From Participant’s Use Of Or

Presence Upon SpiritHorse Connections Therapeutic Center, and the Executive Director’s Property And Facility including without limitation the risk of death, bodily injury, property damage, all kicks, bites, collisions with vehicles, horses, or stationary objects, fire or explosion, the unavailability of emergency care, or the negligence or deliberate act of another person.

3. Participant agrees to hold SpiritHorse Connections Therapeutic Center, the Executive Director and all its successors, assigns, subsidiaries, franchises, affiliates, officers, directors, employees and agents completely harmless and not liable, and releases them from all liability whatsoever, and Agrees Not To Sue them on account of, or in connection with any claims, causes of action, injuries, damages, costs or expenses arising out of the Participant’s use of or presence upon SpiritHorse Connections Therapeutic Center, and the Executive Director’s property and facility, including without limitation, those based on death, bodily injury, or property damage, including consequential damages.

4. Participant agrees to waive the protection afforded by any statute or law in any jurisdiction whose purpose, substance and/or effect is to provide that a general release shall not extend to claims, material or otherwise which the person giving the release does not know or suspect to exist at the time of executing this release.

5. Participant agrees to indemnify and defend SpiritHorse Connections Therapeutic Center and the Executive Director against, and hold it harmless from any and all claims, causes of action, damages judgments, costs or expenses, including attorney’s fees, which in any way arise from the Participant’s use of or presence upon SpiritHorse Connections Therapeutic Center and the Executive Director’s property or facility.

6. Participant agrees to abide by all of SpiritHorse Connections Therapeutic Center’s and the Executive Director’s safety rules and regulations.

7. If Participant is using his/her horse, the horse shall be free from infection, contagious or transmittable disease. SpiritHorse Connections Therapeutic Center and the Executive Director reserve the right to refuse horse if not in proper health, or is deemed dangerous or undesirable.

8. This contract is non-assignable and non-transferable, and is made and entered into in the State of Caliornia, and shall be enforced and interpreted under the laws of this State. Should any be in conflict with State law, then that clause is null and void. When SpiritHorse Connections Therapeutic Center, the Executive Director and Participant, or Participant’s Parent or Legal Guardian if Participant is a minor, sign this contract, it will then be binding on both parties, subject to the above terms and conditions.

Signature: ______Date:____/______/______

If under 18 years of age, parent/guardian signature required below.

Signature:______Date:____/______/______

SpiritHorse Connections Therapeutic Center- Client Application

Hello Riders!

We, as most of you know, have a SpiritHorse Connections Facebook page. We use this page to get information about our program out to the community. This not only helps us stay connected, but also to ask for assistance and resources that we need to be able to continue to provide our services at our low rate. Our supporters and followers enjoy seeing pictures of our riders. Posting pictures is a fun way to get people involved, interested and show the benefits (and fun!) of SpiritHorse. Please indicate whether or not you would like you and/or your rider’s photo shared on our facebook page. Thanks!

_____ Yes, I give permission for SpiritHorse Connections to post photos taken during riding sessions and related events on their facebook page.

_____ No, I do not give SpiritHorse Connections permission to post photos on their facebook page.

Rider Name: ______Date:______

Signature (parent/guardian if under 18):______

SpiritHorse Connections Therapeutic Center- Client Application