GREENLOCK THERAPEUTIC RIDING CENTER, Inc.

55 Summer street – Rehoboth, MA 02769

Telephone: (508) 252-5814

Specializing in hippotherapy treatment

& Offering therapeutic riding

Authorization for Emergency Medical Treatment Form

Participant______ Staff______ Volunteer______

Name: ________________________________________________________________ DOB: _______________

Phone: (H)_________________________ (W)_________________________(C )_________________________

Address: ___________________________________________________________________________________

Email Address: _______________________________________________________________________________

Physician’s Name: ____________________________________ Preferred Medical Facility: ____________________

Health Insurance Company: _____________________________ Policy #: _________________________________

Allergies to medications: ________________________________________________________________________

Current medications: ____________________________________________________________________________

In the event of an emergency, contact:

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 Greenlock Therapeutic Riding Center, Inc. to:

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

2. Release client records upon request to the authorized individual or agency involved in the medical

emergency treatment.

Consent Plan

This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life saving” by

the physician. This provision will only be invoked if the person(s) above is unable to be reached.

Date: ____________ Consent Signature: ___________________________________________________________

Client, Parent or Legal Guardian - Signed in presence of center staff

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:

_______________________________________________________________________________________________

Date: ____________ Consent Signature: ___________________________________________________________

Client, Parent or Legal Guardian - Signed in presence of center staff

A COPY OF THE COMPLETED MEDICAL/HEALTH HISTORY SHOULD BE ATTACHED TO THIS FORM.

GREENLOCK THERAPEUTIC RIDING CENTER, Inc.

55 Summer street – Rehoboth, MA 02769

Telephone: (508) 252-5814

Specializing in hippotherapy treatment

& Offering therapeutic riding

Liability Release

Participant______ Staff______ Volunteer______

WARNING: Under Massachusetts Law, an equine professional is not liable for any injury to, or the death of, a participant in equine activities resulting from the inherent risks of equine activities, pursuant to Chapter 128, Section 2D of the General Laws.

The undersigned, in consideration of the use in any manner of the facilities of Greenlock Therapeutic Riding Center, Inc. (GTRC), including, but not limited to, horseback riding and the receiving of instruction by the undersigned (and / or by ________________________________, a minor child of the undersigned), agree, for themselves (and for said child, if any), to irrevocably waive, release, discharge, and hold harmless GTRC, their owners, directors, officers, employees, and agents, all from and against any and all manner of claims, liability damages, and legal or other notions for loss of damage to personal property of the undersigned (and said child, if any) and personal injury to the undersigned (and said child, if any) which may occur by or through the use of said facilities.

The undersigned is fully aware of the inherent risk involved in dealing with horses; and understands and appreciates the size, strength, unpredictability, and sensitivity of the animal. The undersigned is further aware that equestrian-related activities can be extremely dangerous; that accidents involving horses are frequent, and that the condition of the land is often hazardous, and that the ground and footing is rarely perfect. The undersigned does voluntarily participate in or observe these activities with the knowledge and appreciation of the dangers of potentially bodily harm and hereby agrees to assume any and all risk for property damage including personal injury or death.

________________________________________________________________________________(Participant/Staff/Volunteer name) would like to participate in Greenlock Therapeutic Riding Center's program. I acknowledge the risks of horseback riding; however, I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against Greenlock Therapeutic Riding Center, Inc., its Board of Directors, Instructors, Therapists, Aides, Volunteers and/or Employees for any and all injuries and/or losses I / my son / my daughter / my ward may sustain while participating in Greenlock Therapeutic Riding Center.

All volunteers and staff at GTRC must be fully covered by their own health insurance.

I have read Greenlock's "General Information and Rules" and agree to abide by the rules outlined in that document.

Signed: ____________________________________________________ Date: _____________________

Name: _______________________________________________________________________________

Address______________________________________________________________________________

Phone: (H)______________________________(W)________________________(C )________________

Email Address: _________________________________________________________________________

Health Insurance Company Name: ____________________________________________________________

Policy Details: (Group, ID #) ________________________________________________________________