Participant Registration

Parent/Guardian Information
Relationship to participant*

MotherFatherGuardian
Mother's Name - Primary Contact

First NameLast Name
Father's Name - Primary Contact

First NameLast Name
Guardian Name - Primary Contact

First NameLast Name
Sales Force Full Name - auto populated by logic in Conditions

First NameLast Name

Contact Information
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
Preferred Phone*

MobileHomeWork
Home Phone
Work Phone
Mobile Phone
Military status

Active DutyReserveVeteranDisabled VeteranNot Applicable
Employer/School

EMERGENCY MEDICAL TREATMENT

Equestrian/Participant
In case of emergency:
Primary Emergency Contact*
First and Last Name
Primary Emergency Contact Phone *
Please enter a mobile phone number if possible.
Primary - Relationship to participant*
Secondary Emergency Contact (in case Primary is not immediately available)*
First and Last Name
Secondary Emergency Contact Phone *
Please enter a mobile phone number if possible.
Secondary - Relationship to participant*
Preferred Medical Facility*
Physician's Name*
Physician's Phone Number*
Health Insurance Carrier*
Policy Number*
Any additional health history to be considered by emergency responders:*

0/1000
Please review the two options below and make your selection below.

CONSENT PLAN - 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 New Hope, I authorize New Hope Equine Assisted Therapy to:
1. Secure and retain medical treatment and transportation.
2. Release participants records upon request to the authorized individuals or agency involved in the medical emergency 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 New Hope Equine Assisted Therapy. I understand I will be required to complete a separate NON-CONSENT form.
Emergency Medical Treatment*

ConsentNon-Consent
You have selected non-consent for emergency medical treatment/aid in the event of illness or injury while on the property New Hope Equine Assisted Therapy, you must contact New Hope to request a Non-Consent Form.

Please complete the rest of this registration, then send an email to Program@NewHopeEquine.com to request the form.
To confirm your consent, please type your first and last name below, select the date and check the Electronic Signature box to acknowledge you have read and understand Emergency Medical Treatment Options and have made your selection.
Emergency Medical Consent Typed Signature*
First and Last Name
Emergency Medical Consent Signature Date*

MonthDayYear
Date

Photo/Media Release

1) New Hope Equine Assisted Therapy may use my, my minor child’s, or my ward’s photograph or image in its print, online and video publications;

2) I release of New Hope Equine Assisted Therapy, its employees and any outside third parties from all liabilities or claims that I might assert in connection with the above-described activities and

3) I waive any right to inspect, approve or receive compensation for any materials or communications, including photographs, videotapes, DVDs, website images or written materials, incorporating photos/images of me, my minor child, my ward.

Make your selection from the options below then please type your first and last name, confirm the date and check the Electronic Signature box to acknowledge you have read and understand the options for the Photo/Media release.
Photo/Media - Choose from these options: Consent - I hereby consent to and authorize the following or Non-consent - I do not consent to, nor do I authorize*
Photo/Media Release Typed Signature*
First and Last Name
Date - Photo/Media Release*

MonthDayYear
Date

Legal Agreements
Liability Release

All equine activities at or with New Hope Equine Assisted Therapy involve inherent risks and dangers, which could result in personal injury or death. I/we acknowledge the risks and dangers of a horse-back riding program to myself, my minor child, my ward, or any person(s) I bring onsite to a New Hope Equine Assisted Therapy location or event, however believe that the possible benefits to myself, my child, my ward, are greater than the risks and dangers assumed.

UNDER TEXAS LAW (CHAPTER 87, CIVIL PRACTICE AND REMEDIES CODE), AN EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE ACTIVITES RESULTING FROM THE INHERENT RISK OF EQUINE ACTIVITIES.

WAIVER AND RELEASE OF LIABILITY

I HEREBY, INTENDING TO BE LEGALLY BOUND FOR MYSELF, MY HEIRS AND ASSIGNS, EXECUTORS OR ADMINISTRATORS, EXPRESSLY WAIVE AND RELEASE FOREVER ALL CLAIMS FOR DAMAGES, COMPENSATION, OR LIABILITY ARISING AGAINST NEW HOPE EQUINE ASSISTED THERAPY, IT’S BOARD OF TRUSTEES, INSTRUCTORS, THERAPISTS, AIDS, VOLUNTEERS, AND/OR EMPLOYEES FOR ANY OR ALL PERSONAL INJURY OR DEATH THAT I, MY MINOR CHILD, OR MY WARD MAY SUSTAIN IN CONNECTION WITH THE NEW HOPE EQUINE ASSISTED THERAPY ACTIVITY, REGARDLESS OF WHETHER SUCH PERSONAL INJURY OR DEATH IS CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OR FAULT OF NEW HOPE EQUINE ASSISTED THERAPY, ITS BOARD OF DIRECTORS, GUARANTORS, INSTRUCTORS, THERAPISTS, AIDES, EMPLOYEES AND VOLUNTEERS ("RELEASEES").

INDEMNITY AGREEMENT

I HEREBY EXPRESSLY AGREE TO INDEMNIFY AND HOLD HARMLESS NEW HOPE EQUINE ASSISTED THERAPY, ITS BOARD OF DIRECTORS, GUARANTORS, INSTRUCTORS, THERAPISTS, AIDES, EMPLOYEES OR VOLUNTEERS ("INDEMNITEES") FROM ANY CLAIM FOR PERSONAL INJURY OR DEATH THAT I, MY MINOR CHILD, OR MY WARD MAY SUSTAIN IN CONNECTION WITH NEW HOPE EQUINE ASSISTED THERAPY ACTIVITIES, REGARDLESS OF WHETHER CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OR FAULT OF INDEMNITEES.

I understand that New Hope Equine Assisted Therapy, its Board of Directors, Guarantors, Instructors, Volunteers and/or Staff members (Indemnitees/Releasees) will not be legally liable for any personal injuries or death that I, my minor child, or my ward may sustain in connection with the Equine Activities regardless of any fault or negligence on the part of lndemnitees or Releasees.

The undersigned acknowledges that he/she has read this Registration & Release form in its entirety; that he/she understands the terms of this release and has signed this release voluntarily and with full knowledge of the effects thereof.

Please type your first and last name below, confirm the date and check the Electronic Signature box to acknowledge you have read and understand the liability release.
Liability Release Typed Signature*
First and Last Name
Date - Liability Release *

MonthDayYear

Confidentiality Policy Agreement

At New Hope, we place great importance on protecting the confidential information of our clients, our staff and our volunteers. “Confidential Information” includes, but is not limited to, personally identifiable information such as surnames, telephone numbers, addresses, e-mails, etc., as well as the non-public business records of New Hope. In particular, medical information about clients, and information about their disabilities or special needs, must be protected as Confidential Information. Volunteers shall never disclose Confidential Information to anyone other than New Hope staff. Volunteers must seek staff permission before taking any pictures or videos.

Please type your first and last name below, confirm the date and check the Electronic Signature box to acknowledge you have read and understand the New Hope Confidentiality Policy and agree to abide by same.
Confidentiality Policy Typed Signature*
First and Last Name
Date - Confidentiality Policy *

MonthDayYear
Date

PARTICIPANT CONTRACT
The following are requirements that must be read and adhered to while participating in the lessons offered at New Hope.

PAYMENT FOR LESSONS:

1. Tuition is $60 per lesson, one per week minimum, payable to New Hope by cash, check, or PayPal. Payments may be made weekly or monthly online or by placing your payment in an envelope in the locked mail box to the right of the office door.

2. Payment may also be made when your invoice is emailed to you. There is a link in the invoice which allows you to make payment immediately with your credit/debit card.

3. If the equestrian’s tuition is being funded by a third-party payer, New Hope will invoice the third-party payer. However, the equestrian or parents/guardians of the equestrian are ultimately responsible for payment.

* Please note that all outstanding accounts need to be paid in full prior to starting each September.

ATTENDANCE:

If an equestrian is unable to attend their scheduled lesson, a 24 hour advance notice is appreciated. If an Equestrian does not give adequate notice or is a “no show,” he or she will be charged the entire cost for that lesson. If the equestrian’s tuition is being funded by a third-party payer, the third party payer will not pay for classes and the equestrian will maintain the responsibility of payment.

a. Equestrians with 3 (three) unexcused absences may be removed from the program with the loss of payment received for classes.

b. Emergency situations are the only exception for not calling to cancel.

In the event an equestrian no longer wants to participate in the program, a one-week notice would be greatly appreciated. This allows New Hope to schedule staff, volunteers and horses accordingly.

Please type your first and last name below, confirm the date and check the Electronic Signature box to acknowledge you have read and understand the payment and attendance policy.
Participant Contract Typed Signature*
First and Last Name
Contract Signature Date*

MonthDayYear

SUBMISSION PAGE

Thank you for your interest in New Hope Equine Assisted Therapy. Once you hit the submit button, your application will be sent to our Programming Coordinator. You will be contacted directly by a member of our staff regarding next steps.

You will also be directed to the New Hope Physician Medical Form which must be completed annually or upon any change in health and/or diagnosis. The medical form must be received at New Hope before your registration can be completed and the initial assessment scheduled.
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