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Spirit Open Equestrian Program - Liability Release Waiver

 

 

Equine Activity Liability Release, Waiver of Right to Sue and Assumption of All Risks

Agreement

CAUTION: READ BEFORE SIGNING

State of Virginia Equine Liability Form

Rev 2004

NOTICE: Please read this document before signing. Signing this document affirms that you have read it and

understand it in its entirety.

 

The Equine Activity Liability laws of the State of Virginia, VA. Code Ann. 3.1-796.130, state among its statutory provisions that , NOTICE: Intrinsic dangers in equine activities, include (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 movement, and unfamiliar objects, persons, or other animals; (iii) certain hazards such as surface and subsurface conditions; (iv) collisions with other animals or objects; and (v) the potential of 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. No participant nor any participant's parent, guardian, or representative shall have or make any claim against or recover from any equine activity sponsor, equine professional, or any other person for injury, loss, damage, or death of the participant resulting from any of the intrinsic dangers of equine activities

 

I/We, the undersigned, personally and/or as Parent/Parents/Guardian/Guardians of below named, a minor, for and in consideration of the agreement of the Spirit Open Equestrian Program Inc., to provide riding instruction to said minor, do/does hereby forever release, acquit, discharge, and hold harmless the Spirit Open Equestrian Program Inc. , it officers, directors, board members, agents, owners, employees, representatives, successors, and assigns, for all manner of claims, demands, and damages of every kind and nature whatsoever, which the undersigned or said minor may now or in the future have against Spirit Open Equestrian Program Inc., its officers, directors, board members, agents, owners, employees, representatives, successors, or assigns on account of any personal injuries, physical or mental condition, known or unknown, to the person of said minor, and the treatment thereof, as a result or, or in any way growing out of the acts of the Spirit Open Equestrian Program Inc., its officers, directors, board members, agents, owners, employees, representatives, successors, or assigns,  in rendering the services above described or in any way incidental thereto, except for those caused by the willful misconduct, gross negligence or intentional torts of the above parties, as applicable,. I do/does hereby forever release, acquit, discharge, and hold harmless Fairfax County Board of Supervisors, Fairfax County Park Authority and its officers, employees, and volunteers, too.

I acknowledge and understand the risks and potential risks of horseback riding including, but not limited to: 1) The propensity of an equine to behave in dangerous ways which may result in injury or death to the participant or damage to property; 2) The inability to predict an equines reaction to sound, movement, objects, persons or animals; 3) Hazards of surface or subsurface conditions whether known or unknown. However, I feel the possible benefits to myself/minor child are greater than the risks assumed.

This Equine Activity Liability Release, Waiver of Right to Sue and Assumption of All Risks Agreement (this Agreement) is hereby given by the undersigned to Spirit Open equestrian Program, Fairfax County, Fairfax County Park Authority, Frying Pan Farm Park  equine activity sponsor and/or equine activity professional (the sponsor/professional) and to the sponsor/professional as agent for and for the benefit of each owner of land upon which an equine activity to which this Agreement relates is conducted Owner) and each partner, officer, agent, employee, director, shareholder, subscriber, member, heir, personal representative, successor and assign of the sponsor/professional or owner as their relationship may determine),provides as follows:

In consideration for the opportunities for the opportunities provided by the sponsor/professional and each owner to the undersigned participant (including any minor participant for whom he signs this Agreement) for the enjoyment of equine activities as a participant, the undersigned participant (including any minor participant for whom he signs this Agreement) hereby agrees as follows:

This Agreement is given in part under the Virginia Equine Activity Liability Act (Code of Virginia 3.1-796.130 et seq.) as it may now provide or be hereafter amended (the Act). All terms defined by the Act shall have the same meaning herein, and the Act is hereby incorporated in this Agreement by reference. This Agreement shall be so construed as to provide to the sponsor/professional the fullest protection of a release, waiver of right to sue and assumption of all risks, which is afforded to the sponsor/professional by the Act and by general law.

All pronouns shall be construed to include the masculine, feminine or neuter as well as the plural or singular, as may be appropriate to facilitate the construction of this Agreement in the light of the facts presented.

The participant hereby acknowledges that he has full and complete notice and understanding of the Act and of all the risks inherent in equine activities which may cause, contribute to or result in the death or personal injury of the participant or damage to the participants property (the Risks), including, but not limited to: (i) the propensity of an equine to behave in dangerous ways or to trip and/or fall; (ii) the inability of anyone whomsoever to predict or foresee an equines reaction to excitement, weather conditions, sound, movements, objects, persons, animals, reptiles, birds or insects, and the effects of such reaction; (iii) the hazards of surface or subsurface conditions, including but not limited to objects or conditions on, under or protruding from the surface, both latent and patent; (iv) the hazards which rocks, cliffs, hills, fences, trees, stumps, logs, bridges, ditches and other debris and obstacles, and any equine activity in connection therewith, may forseeably or unforeseeably present; (v) the dangers and risks of tack or harness slipping or breaking for whatever reason; (vi) the dangers and risks of becoming entangled in tack, harness, or vehicles used in an equine activity; (vii) the risks of falling from or otherwise becoming unstable on an equine or a vehicle used in an equine activity for any reason whatsoever or for no identifiable reason; (viii) the dangers of being struck by an equine, by a rider or by a hound; (ix) any negligent act or omission by the sponsor/professional or any owner which causes or results in the death or personal injury of the participant or damage to the participants property; and all other risks associated with horse back riding, ground work and all related activities.

The participant hereby RELEASES and WAIVES all rights which he may have or hereafter against the sponsor/professional and each owner for death, personal injury or property damage which is in any way associated with the Risks; he does hereby WAIVE his right to sue or bring any action against the sponsor/professional or any owner in connection therewith; he agrees to INDEMNIFY and DEFEND the sponsor/professional and each owner from and to HOLD the sponsor/professional and each owner HARMLESS against any such suit or action; and he hereby expressly ASSUMES ALL RISKS AND DANGERS of death, personal injury and property damage which are in any way associated with the Risks enumerated in paragraph 3, above.

The participant hereby authorizes and consents to any emergency, medical care that may at the time appear reasonably appropriate under the circumstances as a result of injury or sickness caused by or incurred in the course of an equine activity.

This Agreement shall remain valid and in full force and effect from and after the date opposite the signature of the participant until expressly revoked by the participant in a written notice personally delivered to the sponsor/professional.

To the extent possible, this Agreement shall be construed in such a manner as will render it, and each provision of it, fully enforceable; but if any provision of this Agreement shall be unenforceable, such provision (or so much thereof as is unenforceable) shall be deleted and the remainder of this Agreement shall continue in full force and effect.

If this Agreement is executed by the undersigned participant for an on behalf of a minor participant named below; the undersigned participant hereby warrants and represents that he is in fact the legal parent or guardian of such minor, with full rights of custody and control; that this Agreement is given on behalf of and is intended to be binding upon said minor participant, his heirs, personal representatives, successors and assigns; and the undersigned participant further agrees that this Agreement shall also be as fully binding on the undersigned participant as if it were entered solely on his own behalf.

This Agreement shall be binding upon the heirs, personal representatives, successors, and assigns of the participant.

I HAVE FULLY READ AND FULLY UNDERSTAND THE FOREGOING EQUINE RELEASE, WAIVER OR RIGHT TO SUE AND ASSUMPTION OF ALL RISKS. I HAVE CONSULTED AND RELIED UPON MY OWN ADVISORS ON ALL QUESTIONS IN CONNECTION THEREWITH, AND I HAVE NOT RELIED UPON THE SPONSOR/PROFESSIONAL OR ANY OWNER FOR ANY ADVICE OR EXPLANATION IN CONNECTION THEREWITH.

I UNDERSTAND THAT THIS IS A LEGAL DOCUMENT. I HAVE READ AND UNDERSTOOD THIS RELEASE AND I UNDERSTAND ALL ITS TERMS. I EXECUTE IT VOLUNTARILY AND WITH FULL KNOWLEDGE OF ITS MEANING AND SIGNFICANCE. I HEREBY ASSUME ALL OF THE RISKS ASSOCIATED WITH EQUINE RELATED ACTIVITIES.

 

 

 

 

Please select who will be participating...
AdultMinorAdult and a Minor
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First Participant/Volunteer/Staff Name

First Name*

Middle Name

Last Name*

Phone*
First Participant/Volunteer/Staff Date of Birth*
First Participant/Volunteer/Staff Information
Role - PLEASE SELECT ONLY ONE *
Equine Assisted Learning Individual
Equine Assisted Learning- Beginner Riding
Equine Assisted Learning Workshops
Equine Assisted Psychotherapy
Occupational Therapy- Hippotherapy
SPIRIT Academy
Staff
Therapeutic Horsemanship
Therapeutic Riding
Visitor / Guest
Volunteer
Please read and claim if participant has any of the listed conditions, precautions or contraindications: History of animal abuse. History of setting fires. Suspected current or past history of physical, sexual and/or emotional abuse. History of seizure disorder. Gross obesity. Medication side effects. Stress-induced reactive airway disease (asthma). Migraines. Actively dangerous to self or others (suicidal, homicidal, aggressive). Actively delirious, demented, dissociated, psychotic, severely confused (including severe delusion involving horses), medically unstable or actively abusing substances).*
No
Yes

If yes, please explain (If no, enter N/A) *
Are you part of an organization/group?*
No
Yes

If yes, please provide your organization's name.

Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each participant, health history review, as well as sanitation and disinfecting practices. Please review following and aknowledge information below.

Symptoms of COVID-19 include:

• Fever

• Fatigue

• Dry cough

• Difficulty breathing

I agree to the following:

 I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.

 I affirm that I, as well as all household members, have not been diagnosed with COVID19 within the last 30 days.

 I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.

 I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a "hot spot" for COVID-19 infections within the last 30 days.

 I understand that SPIRIT and any staff member or volunteer cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each participant

By signing below I agree to each above statement and release the SPIRIT  from any and all liability for the unintentional exposure or harm due to COVID-19.

SPIRIT staff amd volunteers of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.

I udnerstand and agree with statement above*
No
Yes

Click to customize text

Tell us about your goals and expectations, beside basic horsemanship skills*
Posture improvement, muscle tone improvement, balance, or spasam relief
Social and communicational skills improvement
Boosting confidence
Focusing, organizational skills, management and leadership improvement
Anxeity and or depression relief
Emotional support
Having fun
Other (please explain)

If "other"chosen, please explain
First Participant/Volunteer/Staff Signature*
Participant/Volunteer/Staff Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent/Guardian Employer

Employer

Work phone
How did you learn about SPIRIT?

(VolunteerMatch, program, Internet search, friend, volunteer, family member, website, blog, etc.)
Would you like to stay in touch by e-mail to hear about other SPIRIT activities and programs?
Click to customize question*
No
Yes
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian Date of Birth*
Parent or Guardian Information
Role - PLEASE SELECT ONLY ONE *
Equine Assisted Learning Individual
Equine Assisted Learning- Beginner Riding
Equine Assisted Learning Workshops
Equine Assisted Psychotherapy
Occupational Therapy- Hippotherapy
SPIRIT Academy
Staff
Therapeutic Horsemanship
Therapeutic Riding
Visitor / Guest
Volunteer
Please read and claim if participant has any of the listed conditions, precautions or contraindications: History of animal abuse. History of setting fires. Suspected current or past history of physical, sexual and/or emotional abuse. History of seizure disorder. Gross obesity. Medication side effects. Stress-induced reactive airway disease (asthma). Migraines. Actively dangerous to self or others (suicidal, homicidal, aggressive). Actively delirious, demented, dissociated, psychotic, severely confused (including severe delusion involving horses), medically unstable or actively abusing substances).*
No
Yes

If yes, please explain (If no, enter N/A) *
Are you part of an organization/group?*
No
Yes

If yes, please provide your organization's name.

Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each participant, health history review, as well as sanitation and disinfecting practices. Please review following and aknowledge information below.

Symptoms of COVID-19 include:

• Fever

• Fatigue

• Dry cough

• Difficulty breathing

I agree to the following:

 I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.

 I affirm that I, as well as all household members, have not been diagnosed with COVID19 within the last 30 days.

 I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.

 I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a "hot spot" for COVID-19 infections within the last 30 days.

 I understand that SPIRIT and any staff member or volunteer cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each participant

By signing below I agree to each above statement and release the SPIRIT  from any and all liability for the unintentional exposure or harm due to COVID-19.

SPIRIT staff amd volunteers of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.

I udnerstand and agree with statement above*
No
Yes

Click to customize text

Tell us about your goals and expectations, beside basic horsemanship skills*
Posture improvement, muscle tone improvement, balance, or spasam relief
Social and communicational skills improvement
Boosting confidence
Focusing, organizational skills, management and leadership improvement
Anxeity and or depression relief
Emotional support
Having fun
Other (please explain)

If "other"chosen, please explain
Parent or Guardian Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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