General Release

Welcome! We are excited you are interested in our programs at Healing Strides! As the initial on boarding for anyone seeking to be involved in our programs, we have to have these General Releases signed. Please take the time to read through each release, so you fully understand. If you have any questions along the way, please reach out to our office at (540)334-5825.

These General releases are for the Participant/Rider/Client/Volunteer/Visitor/"Field Tripper" seeking services at Healing Strides. This form must be completed to be receive any services, volunteer in programs, or take a general tour/visit at Healing Strides.

Basic Info

We use an online management tool for helping to communicate with all our contacts (we will NEVER sell or share your personal information!)! Please enter your information below. If you are filling this out for multiple Dependents, please be sure you list them each by name.

This info will be used to communicate volunteer opportunities, special events, billing, lesson schedules, fundraisers and other important info from Healing Strides.

Make sure you have access to both the email account and the mobile for texts. If you unsubscribe, we will no longer be able to communicate with you via emails and texts (this includes billing, scheduling, weather related closing, etc.). We CANNOT sign you back up once you unsubscribe.

Who are you filling this form out for?

First Name (self/guardian/parent) *

Last Name (self/guardian/parent) *

Nickname or preferred name

Phone *

I consent to receive SMS notifications, alerts & occasional marketing communication from Healing Strides. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Reason for visiting/filling out paperwork today? *

Field Trip/other expanation: (which school, troop, etc.)

Email - Please be sure you have access to this email, we will be sending next steps. (check you spam) *

Name of Dependent(s)/Child(ren) *

Date of birth *

Date of Birth of Dependent(s)/Child(ren) *

If multiple, please list in order of name(s) given above.

Height of Dependent(s)/Child(ren) *

If multiple, please list in order of name(s) given above.

Weight *

Weight of Dependent(s)/Child(ren) *

If multiple, please list in order of name(s) given above.

Gender *

Gender of Dependent(s)/Child(ren) *

If multiple, please list in order of name(s) given above.

Address *

Additional Address Info

City *

State *

Postal code *

Country *

Photo & Publicity Release

I consent to and authorize the use and reproduction by Healing Strides of VA of all photographs and any other audiovisual materials taken of myself/dependent(s)/Child(ren) for promotional material, educational activities, exhibitions, or for any other use for the benefit of the program.

Check Yes/No for Photo Release *

YES - I CONSENT to photos/publicity release for myself/dependent(s)/child(ren)

NO - I DO NOT CONSENT to photos/publicity release for myself/dependent(s)/child(ren)

Emergency Contact

Emergency Contact Name *

Please enter First and Last Name of contact

Emergency Contact Relation *

Emergency Contact Phone *

Please include Area Code in phone number.

Medical Waiver and Health Information

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving/giving services, or while being on the property of HSVA or activity site, I authorize Healing Strides of VA 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.

This authorization includes X-Ray, hospitalization, medication and any treatment procedure deemed "life-saving" by the physician. This provision will only be invoked if the person consenting below is non-responsive in a medical emergency.

Medical Waiver Release *

I accept the medical waiver for myself/dependent(s)/child(ren)

Pre-existing Health Conditions (put n/a if none) *

Pre-existing health conditions for Dependent(s)/Child(ren) (put n/a if none) *

If multiple, please list in order of name(s) given above and add initials.

Please list any pertinent medication(s) you are taking (including medical marijuana) (put n/a if none) *

Please list any pertinent medication(s) for the Dependent(s)/Child(ren) are taking (including medical marijuana) (put n/a if none) *

If multiple, please list in order of name(s) given above and add initials.

Please note any allergies and if EpiPen or inhaler is used (put n/a if none) *

What is your general health status? Tell us about any special needs or health concerns (ex. bad back, cannot be on feet long periods, etc.) *

What is your Dependent(s)/Child(ren)(s) general health status? (ex. bad back, cannot be on feet long periods, etc.) *

If multiple, please list in order of name(s) given above and add initials.

Do you have health insurance?

Do your Dependent(s)/Child(ren) have health insurance?

Insurance Details - please put company and coverage dates

Have you ever been convicted of a crime?

Have you or your Dependent(s)/Child(ren) ever been convicted of a crime? *

If you/they have been convicted, please explain below:

Important Information & Acceptances

General Liability Release

As a participant with Healing Strides of VA, I acknowledge and understand the risks and potential risks of a horseback and horse related activities in our program including but not limited to, (i) the propensity of an equine to behave in dangerous ways, which may result in injury or death to the participant or damage to property; (ii) the inability to predict an equine's reaction to sound, movements, objects, persons or animals; (iii) hazards of surface or subsurface conditions whether known or unknown; (iv) the condition and age of the equipment or tack, however, I feel that the possible benefits to myself and the participant I work with are greater than the risk I assume. I hereby, intent to be legally bound, for myself, my heirs and assigns, executors or administrators, and waive and release forever all claims for damages against-Healing Strides of VA, their board of directors, instructors, therapists, aides, volunteers, employees and their respective families, for any and all injuries and/or losses I may sustain while participating in Healing Strides of VA. I further certify that the foregoing statements and representations are being made by me knowingly, freely and voluntarily, and I understand that Healing Strides of VA is expressly relying upon the foregoing statements and representations in permitting me to participate in programs at Healing Strides of VA. *

I accept the release of liability for myself/dependent(s)/child(ren)

Confidentiality

ACKNOWLEDGMENT OF HSVA CONFIDENTIALITY POLICY

* Due to the nature HSVA's programs, we are entrusted with sensitive personal information. Our clients are entitled to assurance of protection from unwarranted invasion of personal privacy. The Privacy Act, State and Federal Laws, regulations from licensing agencies and our basic constitutional rights are designed to protect us all from unwarranted invasion of privacy.

* No information about a client, including enrollment or residence, in written or any other form, may be disclosed to any person or organization without proper authorization. (The only exception is in a life-threatening emergency, in which necessary medical information may be disclosed to emergency personnel to expedite treatment). HSVA staff is responsible for reviewing all requests for information to ensure that the proper authorization has been obtained.

* Again, our records contain sensitive client information, which is protected by law from unauthorized disclosure. HSVA holds the moral and legal obligation to protect the interests of both our clients and employees. By signing the confidentiality agreement, I commit to protect the privacy of HSVA clients, both past and present.

* I have read the above and agree to maintain this policy during and after my tenure with HSVA. I realize that this document will become a permanent record at HSVA. I further realize that failure to comply with the policies on confidentiality could impact my involvement at HSVA.

Confidentiality Agreement check below: *

I accept the confidentiality release for myself/dependent(s)/child(ren)

Consent to Electronic Signature

By checking this box you consent to an electronic signature. *

I consent to Electronic Signature for myself/dependent(s)/child(ren)

Signature of self (over age 18)/Legal Guardian/Parent for Liability, Photo, and Medical Releases above: *

Clear