Loudoun Therapeutic Riding 2021 Activity Waiver
General Information
Participant's First Name
Participant's Last Name
Participant's Date of Birth
Home Phone
Cellular Phone
Primary Contact Email
Select activity type
Peaceful Ponies Nature Walk/January 30 walk is full. More dates coming soon!
Volunteer day
PATH Intl. Workshop or Workshop/Certification
Equine-assisted Learning Group
Therapeutic riding/driving lessons
Education or Training
Visitor
LCPS Teacher/Teacher Assistant
College/University
School Visit
Silver Spurs
North Spring Behavioral Healthcare Staff
Name of school or organization if applicable:
PATH Intl. Member# (if applicable for workshops/certification)
Address Line 1
Address Line 2
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Postal Code
Emergency Contact Name:
Emergency Contact Phone:
Special information:
Please note anything below that applies including medications/
medical conditions/ environmental allergies/food allergies/behaviors/ and/or any precautions or limitations:
I agree to adhere to all LTR center policies and safety procedures.
I agree
Parent/Guardian/Caregiver Information/
***REQUIRED IF PARTICIPANT IS UNDER 18
Mother/Guardian
First Name
MI
Last Name
Father/Guardian
First Name
MI
Last Name
Phone (if different from above)
Email (if different from above)
If different from above: Address Line 1
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Postal Code
Releases
PHOTO RELEASE:
Consent to and authorize the use and reproduction by Loudoun Therapeutic Riding Foundation, Inc. of any and all photographs and any other audio/visual materials taken of me and/or my child for promotional material, social media, educational activities, exhibitions or for any other use for the benefit of the program.
Please select...
I consent
I do not consent
Photo release:
First Name
MI
Last Name
Today's Date
Signature: (
MUST BE 18 y.o. to sign.
Type name to sign photo release - required)
Release, Waiver & Indemnity Agreement:
The undersigned (hereinafter referred to as “Rider”), being of legal age or signing in conjunction with a parent or legal guardian if not of legal age, desires to enter upon the premises known as the Morven Park Equestrian Center and/or to use horses and/or facilities either owned or controlled by Loudoun Therapeutic Riding Foundation, Inc. (LTRF), and/or to receive training or instruction from the agents, volunteers , or employees of LTRF, and being fully aware of the risk of injuries and dangers inherent in entering upon said premises and/or the riding and handling of horses, hereby elects voluntarily to enter upon said premises and/or to participate in said activities, and does hereby willingly enter into this Release, Waiver & Indemnity Agreement (“Agreement”). Therefore, in consideration of being permitted to enter upon the premises known as Morven Park Equestrian Center and/or receive instruction or assistance from the agents, volunteers, or employees of LTRF, Rider knowingly and expressly agrees not to sue and to hold harmless and indemnify LTRF, and all of its agents, directors, officers, shareholders, employees, volunteers, consultants, partners, successors and assigns from and against any and all payments, claims, damages, liabilities, suits, losses and expenses, including attorney’s fees and costs, for any accident, damage, loss, injury, illness or death caused to Rider or to Rider’s property, and Rider agrees to assume all risks in riding or otherwise coming in contact with horses, including, without limitation, the risks of accident, damage, loss, injury, illness or death to Rider or to Rider’s property.
Rider acknowledges that Rider has been given
notice of the risks inherent in and intrinsic dangers of equine activities
including (i) the propensity of equines to behave in ways that may result in injury, harm , or death to persons on or around them; (ii) the unpredictability of an equine’s reaction to such things as sounds, sudden movements, and unfamiliar objects, persons, or another animals; (iii) certain hazards such as surface and subsurface conditions; (iv) collisions with other animals or objects; and (v) the potential for a participant acting in a negligent manner that may contribute to injury to the participant or others, such as failing to maintain control over the equine or not acting within the participant’s ability.
Rider expressly agrees to assume all such risks.
This Agreement shall specifically apply to Rider and if the Rider is under the legal age then to Rider’s parent or legal guardian.
Further, pursuant to Virginia Code Section 3.2-6202, Rider (or if the Rider is under the legal age then Rider’s parent or legal guardian) knowingly and expressly waives his or her right to sue and agrees to assume all the risks specifically listed in the prior paragraph.
If Rider is a minor or otherwise under a legal disability, this Agreement shall be executed by Rider’s parent or legal guardian.
By signing, the parent or legal guardian agrees (i) to waive the parents, guardians, and Rider’s rights to sue the parties named in the immediately preceding paragraph; (ii) to assume, on behalf of the parent, guardian, and Rider, the risks set forth in the immediately preceding paragraph, in addition to all other risks of riding or otherwise coming into contact with horses; and (iii) to hold harmless and indemnify LTRF, and all of its agents, directors, officers, shareholders, employees, volunteers, consultants, partners, successors and assigns from and against any and all payments, claims, damages, liabilities, suits, losses and expenses, including attorney’s fees and costs, for any accident, damage, loss, injury, illness or death caused to Rider or to Rider’s property, and Rider agrees to assume all risks in riding or otherwise coming in contact with horses, including, without limitation, the risks of accident, damage, loss, injury, illness or death to Rider or to Rider’s property.
It is expressly agreed by Rider and any parent or guardian whose signature appears on this document that this Agreement shall be governed and construed as being sufficient to satisfy the assumption of risk and waiver requirements necessary to relieve equine activity sponsors and equine professionals from liability under the Virginia Equine Liability Act (Virginia Code Section 3.2-6200 et seq.), and that LTRF, and all of its agents, directors, officers, shareholders, employees, volunteers, consultants, partners, successor and assigns are covered by the provisions of the Virginia Equine Liability Act (Virginia Code Section 3.2-6200 et seq.).
This Agreement shall be governed and construed by the laws of the Commonwealth of Virginia, regardless of where any accident, damage, loss, injury, illness or death shall occur.
In the event that any portion of this Agreement shall be declared unenforceable, such declaration shall not affect the remaining terms of this Agreement, which shall survive intact. Rider has been advised to wear protective headgear and hard-soled shoes; heeled footwear at all times while riding or otherwise coming in contact with horses, and expressly assumes the risk of injury resulting from the failure to do so and/or from selecting headgear or footwear which does not adequately protect against injury.
Caution: Read before signing
.
SIGNATURE: MUST BE 18 y.o. to sign. Type your name below to agree and sign (Required):
Today'Date
Thank you!
We look forward to welcoming you to LTR! Please take a moment to read LTR Center Policies located on our website. You will now be redirected to
ltrf.org
.
Contact Information