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Mailing address: 1704 Winston Court Woodstock GA 30189
Facility address: 75 Red Gate Trail Canton Ga 30115
Email: bethany@beats-inc.org
Phone: 404-644-3917 Fax: 678-494-6616

LIABILITY RELEASE

WARNING 

Under  Georgia Law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities pursuant to Chapter 12 of Title 4 of the Official Code of Georgia Annotated

Client would like to participate in the Bethany's Equine and Aquatic Therapy Services, Inc (BEATS, Inc) program. I acknowledge the risks and potential for risks of horseback riding programs. However, I feel that the possible benefits to me/my ward are greater than the risk assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, indemnify, hold harmless, waive and release forever all claims for damages against BEATS, Inc., its Board of Directors, Instructors,. Therapists, Aides, Volunteers and/or Employees, as well as the owners of the property, Mariposa Farms, LLC, their officers and family members, agents, employees, and contractors for any and all injuries and/or losses, including theft, loss of property, or death that I may sustain while participating in the BEATS, Inc program.

Client or Parent/Guardian Signature


Date: February 22, 2020

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Age *
It is the mission of BEATS, Inc to provide hippotherapy and therapeutic riding services to individuals with special needs. However, to help support our program, BEATS, Inc provides lessons to typical riders as well. *
This rider has physical, cognitive or emotional/behavioral needs (Please fill out additional papers if required)
This rider has no special needs
Participant is a volunteer

PHOTO RELEASE

I hereby consent to and authorize the use and reproduction of any and all photographs and other audiovisual materials taken of me, my son, daughter or ward for promotional printed material and/or educational activities for BEATS, Inc. program.

PHOTO RELEASE*

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT


Physician's Name *

Preferred Medical Facility *

Relevant Medical conditions/Medications

Allergies

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 below is unable to be reached.

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 is required, I wish the following procedures to take place:

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Age *
It is the mission of BEATS, Inc to provide hippotherapy and therapeutic riding services to individuals with special needs. However, to help support our program, BEATS, Inc provides lessons to typical riders as well. *
This rider has physical, cognitive or emotional/behavioral needs (Please fill out additional papers if required)
This rider has no special needs
Participant is a volunteer

PHOTO RELEASE

I hereby consent to and authorize the use and reproduction of any and all photographs and other audiovisual materials taken of me, my son, daughter or ward for promotional printed material and/or educational activities for BEATS, Inc. program.

PHOTO RELEASE*

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT


Physician's Name *

Preferred Medical Facility *

Relevant Medical conditions/Medications

Allergies

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 below is unable to be reached.

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 is required, I wish the following procedures to take place:

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Age *
It is the mission of BEATS, Inc to provide hippotherapy and therapeutic riding services to individuals with special needs. However, to help support our program, BEATS, Inc provides lessons to typical riders as well. *
This rider has physical, cognitive or emotional/behavioral needs (Please fill out additional papers if required)
This rider has no special needs
Participant is a volunteer

PHOTO RELEASE

I hereby consent to and authorize the use and reproduction of any and all photographs and other audiovisual materials taken of me, my son, daughter or ward for promotional printed material and/or educational activities for BEATS, Inc. program.

PHOTO RELEASE*

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT


Physician's Name *

Preferred Medical Facility *

Relevant Medical conditions/Medications

Allergies

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 below is unable to be reached.

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 is required, I wish the following procedures to take place:

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Age *
It is the mission of BEATS, Inc to provide hippotherapy and therapeutic riding services to individuals with special needs. However, to help support our program, BEATS, Inc provides lessons to typical riders as well. *
This rider has physical, cognitive or emotional/behavioral needs (Please fill out additional papers if required)
This rider has no special needs
Participant is a volunteer

PHOTO RELEASE

I hereby consent to and authorize the use and reproduction of any and all photographs and other audiovisual materials taken of me, my son, daughter or ward for promotional printed material and/or educational activities for BEATS, Inc. program.

PHOTO RELEASE*

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT


Physician's Name *

Preferred Medical Facility *

Relevant Medical conditions/Medications

Allergies

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 below is unable to be reached.

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 is required, I wish the following procedures to take place:

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Age *
It is the mission of BEATS, Inc to provide hippotherapy and therapeutic riding services to individuals with special needs. However, to help support our program, BEATS, Inc provides lessons to typical riders as well. *
This rider has physical, cognitive or emotional/behavioral needs (Please fill out additional papers if required)
This rider has no special needs
Participant is a volunteer

PHOTO RELEASE

I hereby consent to and authorize the use and reproduction of any and all photographs and other audiovisual materials taken of me, my son, daughter or ward for promotional printed material and/or educational activities for BEATS, Inc. program.

PHOTO RELEASE*

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT


Physician's Name *

Preferred Medical Facility *

Relevant Medical conditions/Medications

Allergies

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 below is unable to be reached.

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 is required, I wish the following procedures to take place:

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Age *
It is the mission of BEATS, Inc to provide hippotherapy and therapeutic riding services to individuals with special needs. However, to help support our program, BEATS, Inc provides lessons to typical riders as well. *
This rider has physical, cognitive or emotional/behavioral needs (Please fill out additional papers if required)
This rider has no special needs
Participant is a volunteer

PHOTO RELEASE

I hereby consent to and authorize the use and reproduction of any and all photographs and other audiovisual materials taken of me, my son, daughter or ward for promotional printed material and/or educational activities for BEATS, Inc. program.

PHOTO RELEASE*

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT


Physician's Name *

Preferred Medical Facility *

Relevant Medical conditions/Medications

Allergies

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 below is unable to be reached.

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 is required, I wish the following procedures to take place:

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Age *
It is the mission of BEATS, Inc to provide hippotherapy and therapeutic riding services to individuals with special needs. However, to help support our program, BEATS, Inc provides lessons to typical riders as well. *
This rider has physical, cognitive or emotional/behavioral needs (Please fill out additional papers if required)
This rider has no special needs
Participant is a volunteer

PHOTO RELEASE

I hereby consent to and authorize the use and reproduction of any and all photographs and other audiovisual materials taken of me, my son, daughter or ward for promotional printed material and/or educational activities for BEATS, Inc. program.

PHOTO RELEASE*

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT


Physician's Name *

Preferred Medical Facility *

Relevant Medical conditions/Medications

Allergies

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 below is unable to be reached.

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 is required, I wish the following procedures to take place:

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Age *
It is the mission of BEATS, Inc to provide hippotherapy and therapeutic riding services to individuals with special needs. However, to help support our program, BEATS, Inc provides lessons to typical riders as well. *
This rider has physical, cognitive or emotional/behavioral needs (Please fill out additional papers if required)
This rider has no special needs
Participant is a volunteer

PHOTO RELEASE

I hereby consent to and authorize the use and reproduction of any and all photographs and other audiovisual materials taken of me, my son, daughter or ward for promotional printed material and/or educational activities for BEATS, Inc. program.

PHOTO RELEASE*

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT


Physician's Name *

Preferred Medical Facility *

Relevant Medical conditions/Medications

Allergies

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 below is unable to be reached.

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 is required, I wish the following procedures to take place:

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Age *
It is the mission of BEATS, Inc to provide hippotherapy and therapeutic riding services to individuals with special needs. However, to help support our program, BEATS, Inc provides lessons to typical riders as well. *
This rider has physical, cognitive or emotional/behavioral needs (Please fill out additional papers if required)
This rider has no special needs
Participant is a volunteer

PHOTO RELEASE

I hereby consent to and authorize the use and reproduction of any and all photographs and other audiovisual materials taken of me, my son, daughter or ward for promotional printed material and/or educational activities for BEATS, Inc. program.

PHOTO RELEASE*

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT


Physician's Name *

Preferred Medical Facility *

Relevant Medical conditions/Medications

Allergies

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 below is unable to be reached.

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 is required, I wish the following procedures to take place:

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Age *
It is the mission of BEATS, Inc to provide hippotherapy and therapeutic riding services to individuals with special needs. However, to help support our program, BEATS, Inc provides lessons to typical riders as well. *
This rider has physical, cognitive or emotional/behavioral needs (Please fill out additional papers if required)
This rider has no special needs
Participant is a volunteer

PHOTO RELEASE

I hereby consent to and authorize the use and reproduction of any and all photographs and other audiovisual materials taken of me, my son, daughter or ward for promotional printed material and/or educational activities for BEATS, Inc. program.

PHOTO RELEASE*

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT


Physician's Name *

Preferred Medical Facility *

Relevant Medical conditions/Medications

Allergies

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 below is unable to be reached.

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 is required, I wish the following procedures to take place:

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT*
Participant's 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's Email Address

Email*

Confirm Email*
EMERGENCY CONTACTS

Name *

Relationship *

Phone *

Name *

Relationship *

Phone *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those 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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Age *
It is the mission of BEATS, Inc to provide hippotherapy and therapeutic riding services to individuals with special needs. However, to help support our program, BEATS, Inc provides lessons to typical riders as well. *
This rider has physical, cognitive or emotional/behavioral needs (Please fill out additional papers if required)
This rider has no special needs
Participant is a volunteer

PHOTO RELEASE

I hereby consent to and authorize the use and reproduction of any and all photographs and other audiovisual materials taken of me, my son, daughter or ward for promotional printed material and/or educational activities for BEATS, Inc. program.

PHOTO RELEASE*

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT


Physician's Name *

Preferred Medical Facility *

Relevant Medical conditions/Medications

Allergies

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 below is unable to be reached.

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 is required, I wish the following procedures to take place:

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT*
Parent or Guardian's 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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