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Liability Waiver, Assumption of Risk, Photo Release and Disclosure of Personal Information Agreement

To owners of Heart Lake Farm, Jessica and Scott Lake, as well as their employees and representatives, hereinafter referred to as “HLF,” for all educational and leisure activities, horse related care, horseback riding and other equestrian activities at 6207 and 6215 Welch Rd., Saanichton BC, V8M 1W7. This includes, but is not limited to, services provided at Heart Lake Farm by the following individuals and organizations: Together in Stride, Human-Nature Counselling Society and Lisa Hartwick.

I acknowledge that Heart Lake Farm is a working farm that presents inherent dangers including varied terrain, bodies of water, equipment and machinery, wild animals and livestock. I agree to abide by all rules and directions, use common sense and act with awareness of my own physical abilities and limitations. I acknowldege that I am participating in Heart Lake Farm educational and leisure activities at my own risk and choice. 


I acknowledge that horse care, horseback riding and other equestrian activities are high risk activities and that I am participating at my own risk and choice, and I am in full knowledge of the potential hazards which are inherent in the sport.


I further acknowledge the inherent risks in horseback riding and being around horses, which include bodily injury to people in the presence of horses, which can result from normal use, care and schooling. 


In consideration of being allowed to participate in educational and leisure acitivies, horse care, horseback riding and other equestrian activities at 6207 and 6215 Welch Road, I hereby assume all risk and I hereby release HLF from responsibility, liability and all claims of any nature and any kind which I may have from my participation, including but not limited to bodily injury or death to myself or my horse or any minors in my care, and damage to property arising from any cause whatever, including negligence of the HLF. 


This agreement and any rights, duties and obligations between the parties to this agreement shall be governed by and interpreted solely in accordance with the laws of the Province of British Columbia and no other jurisdiction. Any litigation involving the parties to this agreement shall be brought solely within the Province of British Columbia and shall be made within the exclusive jurisdiction of the Courts of the Province of British Columbia. 


I hereby declare that in signing this agreement I have read and fully understand and agree to the terms and conditions stated herein and that it is binding upon my executors, heirs and assigns.  


Today's Date: October 8, 2024

First Participants Name

First Name*

Last Name*

Phone*
First Participants Age Acknowledgment*
First Participants Date of Birth*
I certify that I am 18 years of age or older
First Participants Information

Preferred Pronouns:
First Participants Signature*
Second Participants Name

First Name*

Last Name*
Second Participants Date of Birth*
Second Participants Information

Preferred Pronouns:
Third Participants Name

First Name*

Last Name*
Third Participants Date of Birth*
Third Participants Information

Preferred Pronouns:
Fourth Participants Name

First Name*

Last Name*
Fourth Participants Date of Birth*
Fourth Participants Information

Preferred Pronouns:
Fifth Participants Name

First Name*

Last Name*
Fifth Participants Date of Birth*
Fifth Participants Information

Preferred Pronouns:
Sixth Participants Name

First Name*

Last Name*
Sixth Participants Date of Birth*
Sixth Participants Information

Preferred Pronouns:
Seventh Participants Name

First Name*

Last Name*
Seventh Participants Date of Birth*
Seventh Participants Information

Preferred Pronouns:
Eighth Participants Name

First Name*

Last Name*
Eighth Participants Date of Birth*
Eighth Participants Information

Preferred Pronouns:
Ninth Participants Name

First Name*

Last Name*
Ninth Participants Date of Birth*
Ninth Participants Information

Preferred Pronouns:
Tenth Participants Name

First Name*

Last Name*
Tenth Participants Date of Birth*
Tenth Participants Information

Preferred Pronouns:
Participants 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*
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Participants Consent
PHOTOGRAPH AND VIDEO RELEASE CONSENT: I give permission to Heart Lake Farm owners, staff and associates to photograph/video me and use such photograph(s)/video(s) in all forms of media, for any and all promotional purposes including advertising, display, audiovisual, exhibition or editorial use. I understand that no payment or compensation will be provided. My name will not be used without separate prior consent in specific cases.*
Yes this is fine with me
No - I will contact jess@heartlakefarm.ca to discuss
CONSENT TO SHARING OF PERSONAL INFORMATION: I understand that the information I have provided in this document, and in any communication and forms regarding registration or appointment booking, as well as information I provide or observations made of my activities during my time at the farm, may be shared among staff of Heart Lake Farm for the purpose of program delivery, professional development or emergency response. Identifying information will never be shared with anyone outside of farm staff for any reason, except in the case of a medical emergency where I cannot speak for myself.*
Yes this is fine with me
No - I will contact jess@heartlakefarm.ca to discuss
As parent/guardian of Minor I acknowledge that I have read and fully understand and agree to the terms and conditions stated herein on behalf of Minor and myself.


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's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Preferred Pronouns:
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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