Reining Strength EAL Client Application

Client Name

Birthdate

Nickname

Gender

Height

Weight

Medical Condition

Medications

Ethnicity

County

Parent/Guardian #1 Information

First Name

Last Name

Employer

Home Phone

Cell Phone

Work Phone

Preferred Phone

Mailing Address

City

State

Zip

Parent/Guardian #2 Information

First Name

Last Name

Employer

Home Phone

Cell Phone

Work Phone

Preferred Phone

Mailing Address

City

State

Zip

Designated Caregiver Information

Designated Caregiver First Name

Last Name

Home Phone

Cell Phone

Work Phone

Client School/Employer Information

School/Employer Name

Grade Completed

Secondary School Program (if applicable)

Referral Information

How did you hear about Us?

Referring Group/Company/Organization

Contact Name

Phone

Military Service

Served in Military

Rank

Branch

Dependent of Military Service Member

Name of Service Member

Relationship to client

Photo Release

I consent to and authorizeI do NOT consent to

For valuable consideration given and which is hereby acknowledged, the undersigned hereby grants to Reining Strength Therapeutic Horsemanship permission to take, or have taken, still and moving photographs and films of the above named individual, including television pictures, and consents and authorizes Reining Strength Therapeutic Horsemanship, its advertising agencies, news media, and any other persons interested in Reining Strength Therapeutic Horsemanship and its work, to use and reproduce the photographs, films or pictures, and to circulate and publicize the same by all means, including, without limiting the generality of the foregoing, newspapers, television media, brochures, pamphlets, instructional materials, books, and clinical materials. Please note that your presence or participation in a public event at Reining Strength Therapeutic Horsemanship or event involving Reining Strength Therapeutic Horsemanship constitutes a tacit waiver of this non-consent. Electing the non-consent option will not necessarily prevent a subject from being photographed or filmed at any such event by Reining Strength Therapeutic Horsemanship or the general public. With respect to the foregoing matters, no inducements or promises have been made to secure this signature to this release other than the intention of Reining Strength Therapeutic Horsemanship to use, or cause to be used, such photographs, films, and pictures for the primary purpose of promoting Reining Strength Therapeutic Horsemanship and its work.

By entering my name below I agree the photo release statement above.

Client Name

Date

Liability Release

the undersigned adult as client, or parent or guardian of

, a minor, would like to participate at Reining Strength Therapeutic Horsemanship.

I acknowledge the risks and potential for risks of equine activities. I understand that I/my son/daughter/ward, will be working with and around horses, as well as, riding horses at Reining Strength Therapeutic Horsemanship. However, I feel that the possible benefits to myself/son/daughter/ward are greater than the risk assumed. I, the undersigned client and/or parent or guardian, hereby, intending to be legally bound, for myself, my heirs, and assigns, executors or administrator, waive and forever release, acquit, discharge and hold harmless all claims for damages against Reining Strength, its board of directors, trustees agents, instructors, therapists, employees, representatives, volunteers, owners of property on which Reining Strength Therapeutic Horsemanship operates, successors or assigns on account of any personal injuries and/or personal damages known or unknown, or in any way growing out of, the acts of Reining Strength Therapeutic Horsemanship, its board of directors, trustees, agents, instructors, therapists, employees, representatives, volunteers, owners of the property on which Reining Strength Therapeutic Horsemanship operates, successors or assigns.

By entering my name below I understand that under TEXAS LAW (CHAPTER 87, CIVIL PRACTICE AND REMEDIES CODE), A FARM ANIMAL PROFESSIONAL OR FARM OWNER OR LESSEE IS NOT LIABLE FOR
AN INJURY TO OR THE DEATH OF A PARTICIPANT IN FARM ANIMAL ACTIVITIES, INCLUDING AN EMPLOYEE OR INDEPENDENT CONTRACTOR, RESULTING FROM THE INHERENT RISKS OF FARM ANIMAL ACTIVITIES.

Date

Authorization for Emergency Medical Treatment

Client Complete Legal Name

Date of Birth

Physician Name

Medical Office/Facility

Health Insurance Company

Insurance Status

Current Medications

Allergies (medications/food/other)

Emergency Contact Information

#1 Name

Home Phone

Cell Phone

Work Phone

#2 Name

Home Phone

Cell Phone

Work Phone

#3 Name

Home Phone

Cell Phone

Work Phone

Medical Treatment Consent

In the event that medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on Reining Strength Therapeutic Horsemanship property, I authorize Reining Strength Therapeutic Horsemanship to:

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

2. Release client/participant's records upon request to the authorized individual or agency involved in the medical emergency treatment

This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed "life-saving" by the physicians. This provision will only be invoked if none of the Emergency Contacts listed above can be reached.

By entering my name below I agree the medical treatment statement above.

Date

Contact Information