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Horse Sense of the Carolinas

and Heart of Horse Sense

7041 Meadows Town Road

Marshall, North Carolina 28753

828-777-5199


Email: programs@heartofhorsesense.org

HORSE SENSE GENERAL LIABILITY WAIVER, RELEASE, HOLD HARMLESS AND RISK ACKNOWLEDGEMENT AGREEMENT AND MEDIA RELEASE FORM

WARNING:

UNDER NORTH CAROLINA LAW, AN EQUINE OR FARM ANIMAL ACTIVITY SPONSOR OR AN EQUINE OR FARM ANIMAL PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE OR FARM ANIMAL ACTIVITIES RESULTING EXCLUSIVELY FROM THE INHERENT RISKS OF EQUINE AND FARM ANIMAL ACTIVITIES. CHAPTER 99E OF THE NORTH CAROLINA GENERAL STATUTES

1. Parties. The parties to this GENERAL LIABILITY WAIVER, RELEASE, HOLD HARMLESS AND RISK ACKNOWLEDGMENT AGREEMENT (the “Agreement”) are Horse Sense of the Carolinas, Inc., a North Carolina corporation and/or Heart of Horse Sense, Inc., a North Carolina nonprofit corporation (either or both, as applicable, being referred to herein as “HS”), and the Participant on this form, a trainee, client, student or visitor of or to the Farm or Offsite (both as defined below) or a guest of any of the foregoing (all such individuals being collectively referred to herein as a “Participant”).

2. Participation in HS Program(s). In exchange for Participant’s acceptance of the terms of this Agreement and his or her signature hereon acknowledging same, HS agrees to permit Participant to be present on all or a portion of (as determined by HS in its sole discretion) the property located at 7041 Meadows Town Road, Marshall, North Carolina 28753 (the “Farm”) or at another location as part of a HS event (“Offsite”).

3. Nature of Equestrian and Farm Animal Activities. Numerous obvious and non-obvious risks are inherent and always present in horseback riding and other equestrian-related and other farm animal-related activities, despite all safety precautions. By way of example and not limitation, horses, ponies and other farm animals may, among other things, stop short, suddenly change direction or speed, shift their weight from side to side, trip, fall, buck, spit, rear, bite, kick or run from what they perceive (correctly or incorrectly) as danger. These enumerated and related or similar risks, as well as the more general farm risks described in paragraph 4 below, among others, exist for anyone who is in close proximity to a horse or other farm or wild animal, whether mounted or on the ground.

Participant acknowledges these and similar or related risks and affirmatively states that they are not relying on HS to advise them of all possible risks.

4. Nature of Farm Activities. Numerous obvious and non-obvious risks are inherent and always present in a farm setting, despite all safety precautions. In addition to the risks related to equines and equestrian activities and other farm animal activities and farm activities in general some of which are detailed in paragraph 3 above, there are other risks present. By way of example and not limitation, (a) electric fencing and farm equipment is used regularly around the Farm or Offsite and can give rise to risks associated with electric fencing and the operation of heavy equipment; (b) farm animals such as horses, llamas, ostriches, alpacas, chickens, roosters, cats, dogs, cows and goats, among others, as well as wild animals naturally present in rural settings such as raccoons, foxes, deer, bobcats, coyotes, beavers, geese, groundhogs, wild turkeys, skunks, opossums and bears, among others, and such are unpredictable and can chase, attack, scratch, bite and injure humans and/or other animals present on the Farm or Offsite, (c) fertilizers, pesticides and animal medications are present on the Farm or Offsite and can cause property damage or personal injury to humans and animals if encountered, handled or misused; (d) all types of insects, rats, snakes, spiders and other pests and vermin may at any time be present on the Farm or Offsite and can cause property damage and personal injury to humans and other animals; (e) ponds, creeks and other water features on the Farm or Offsite can present safety hazards, including risk of drowning or other water associated risks; (f) uneven terrain, ditches, sinkholes, deep mud, dead trees, fallen trees and other associated risks; (g) infectious bacteria, viruses, fungi/mold, parasites or other agents which may be present on the Farm or Offsite (as they are in most outdoor locations) and can cause infection (including, but not limited to, the novel coronavirus known as COVID-19 and other rhino or coronaviruses as well as rabies, hepatitis, pneumonia and meningitis-causing viruses, among others; bacteria commonly known as tetanus, Salmonella, E. Coli, Staphylococcus, Streptococcus and tuberculosis, among others; fungus commonly known as Candida (yeast), aspergillus (mold) and ringworm, among others; various parasitic organisms such as giardia, pinworm, toxoplasma, hookworm, tapeworm, roundworm, scabies, among others, and all other infectious agents) in humans, including Participant, as well as in animals; and (h) any and all other potential risks that may be associated with the operation of an agricultural, equestrian, commercial or residential facility.

Again, Participant acknowledges these and similar or related risks and affirmatively state that they are not relying on HS to advise them of all possible risks.

5. Waiver, Release and Indemnification. In consideration for Participant’s ability to use and/or be present at the Farm or Offsite, Participant agrees, to the extent permitted by law, to release and hold harmless HS and their respective founders, officers, directors, volunteers, employees, representatives, agents, assigns, affiliated individuals or organizations (whether nonprofit or for profit), sponsors, insurers and others acting on behalf of any of them (all of which entities and individuals being collectively referred to herein as “HS Indemnified Parties”) from all losses, claims, injuries, demands, causes of action and legal liability (collectively, “Losses”) related to Participant’s (or Participant’s horse’s or his or her other animals’ presence at the Farm or Offsite, if applicable) whether the same be known or unknown, anticipated or unanticipated, foreseeable or unforeseeable, and even if such Losses are the result of the negligence and/or acts or omissions of HS Indemnified Parties or other individuals present on the Farm or Offsite.

 Participant further agrees to waive all claims which may otherwise arise from an injury to Participant while using or being present at the Farm or Offsite or any activity or program offered by HS and shall not pursue any claims, demands or causes of action against any HS Indemnified Parties for any economic or non-economic losses due to Participant’s bodily injury, death or property damage arising out of the activities and programs offered by HS or Participant’s use of or presence at the Farm or Offsite.

 Participant agrees to be responsible for any and all damages, injuries and/or loss of life caused by Participant (or caused by a horse owned by or in the care, custody or control of Participant or any other animal brought to the Farm or Offsite by Participant) and to indemnify HS Indemnified Parties from any losses or expenses, including but not limited to attorneys’ fees, which each such HS Indemnified Party incurs in connection with any such damages, injuries and/or loss of life.

6. Assumption of Risk. Participant acknowledges that failure to follow HS’ rules and/or the directions of HS’ volunteers or staff, all of which are incorporated herein by reference, may put him or her (or his or her horse or other animal, if applicable) at risk of, or increase the risk of, injury or death. Participant acknowledges that he or she, as the case may be, bears the responsibility for Participant’s safety and Participant should not participate in any equestrian or farm activity unless he or she is confident that Participant can do so safely. Participation in equestrian or farm activities at or with HS constitutes a knowing and voluntary assumption of all risks associated with such activities and those associated with being present at HS’ facilities, including but not limited to inherent risks and the risk of negligence by HS or others. This assumption of risk is intended to operate as a bar to recovery for any claim for property damage, injury or death.

7. Helmet Requirement. HS requires that if Participant is ever riding any horse or other animal at the Farm or Offsite that Participant provide and wear his or her own properly fitting ASTM/SEI certified riding helmet. Participant acknowledges that wearing a properly fitted and secured equestrian riding helmet which meets or exceeds the quality standard of the SEI Certified ASTM Standard F1163 while riding, mounting, dismounting and being near horses or other animals may reduce the severity of head injuries sustained or prevent death as the result of a fall or other occurrence. HS makes no representation as to the condition, effectiveness or suitability of any helmet used by Participant. Participant further assumes all helmet related risks. It is also required that anyone riding at the Farm or Offsite in close proximity to equines on the Farm or Offsite wear closed-toed shoes or boots with a hard sole and heel.

8. Guests. Participant understands and acknowledges that he or she is not permitted to bring a guest who has not executed this Agreement to the Farm or Offsite. However, should Participant bring to HS’ facilities an individual who has not executed a copy of this Agreement in violation hereof, Participant shall be solely responsible for the safety of the guest, be responsible for any property damage, personal injury or loss of life caused by or suffered by such guest and further indemnify HS from any losses or expenses, including but not limited to attorneys’ fees, which HS incurs in connection with any such damages, injuries and/or loss of life caused by or suffered by such guest.

9. Permission to Treat Participant and Participant’s Animals. Participant understands that HS does not typically administer medications to animals and will typically do so only when directed in writing by Participant. However, in the unexpected event of a medical emergency, Participant agrees that the employees or agents of HS have Participant’s permission to provide, seek and authorize medical, veterinary or farrier attention and services, including but not limited to first aid or emergency medical services for the Participant or for any veterinary or farrier attention or services for any horse or other animal owned, leased or in the care of the Participant. Further, Participant agrees that HS shall bear no liability in connection with its provision and authorization of such medical, veterinary and farrier attention and services and Participant shall be solely responsible for any costs associated with such first aid, medical, veterinary and farrier services.

10. Barn Rules. Participant understands and agrees that he or she must at all times abide by the Barn Rules which are from time to time promulgated and amended by HS. The Barn Rules are intended to keep Participants and others on the Farm and Offsite safe from harm and failing to abide by the Barn Rules can potentially endanger the Participants and others on the Farm and Offsite.

11. Dogs/Other Pets. HS dogs are permitted on the Farm or Offsite and Participant understands and agrees that other than such HS dogs, only residents of the Farm or Offsite residents, boarders of horses on the Farm or Offsite lessees of horses boarded on the Farm or Offsite are permitted to bring leashed, non-dangerous, trained, well- mannered dogs with no history of causing property damage or personal injury to the Farm or Offsite; and that no other pets may be brought on the Farm or Offsite by any person. If a Participant or a guest of a Participant fails to abide by these requirements and brings a dog or other animal onto the Farm or Offsite and as a result an injury, property damage and/or loss of life occurs, Participant shall indemnify and hold HS Indemnified Parties harmless from and against any losses or expenses, including but not limited to attorneys’ fees, which each such HS Indemnified Party incurs in connection with any such damages, injuries and/or loss of life.

12. Parent/Legal Guardian. If Participant is a minor, Participant’s parent or legal guardian (the “Participant Responsible Party”) has executed this Agreement with regard to Participant and wherever the word “Participant” appears herein, such Participant Responsible Party’s name shall be imputed so that any waivers, releases and indemnities provided herein that are required of Participant are also required of Participant Responsible Party and are operative with regard to Participant Responsible Party such that they waive, release and indemnify all HS Indemnified Parties to the fullest extent permitted by law.

13. Miscellaneous. This Agreement: (a) contains the entire agreement between Participant and HS and supersedes all prior written or oral understandings among the same regarding the terms hereof; (b) may not be amended or modified except in a writing signed by Participant and an authorized representative of HS; (c) shall be construed and enforced in accordance with the laws of the State of North Carolina; (d) has been carefully reviewed and is fully understood by the Participant and, if desired, has been reviewed by Participant’s independent counsel; (e) shall be binding upon HS, Participant and their successors, assigns, heirs and personal representatives; and (f) shall be for the benefit of HS. Participant and HS both irrevocably consent to the exclusive jurisdiction of the courts of Buncombe County, North Carolina as the appropriate venue for the resolution of any disputes which may arise hereunder. When the contexts in which words are used in this Agreement indicate that such is the intent, words in the singular shall include the plural and vice versa. The Parties further agree that if any paragraph or part of this Agreement is found to be void or unenforceable, the remainder of this Agreement shall remain in full force and effect and shall not be affected by such a finding.

14. Media Release. Participant gives HS their permission to take photographs and share their likeness, including any images or recordings, during their visit to the farm, for promotional and educational purposes.

WARNING:

UNDER NORTH CAROLINA LAW, AN EQUINE OR FARM ANIMAL ACTIVITY SPONSOR OR AN EQUINE OR FARM ANIMAL PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE OR FARM ANIMAL ACTIVITIES RESULTING EXCLUSIVELY FROM THE INHERENT RISKS OF EQUINE AND FARM ANIMAL ACTIVITIES. CHAPTER 99E OF THE NORTH CAROLINA GENERAL STATUTES

Shannon Knapp & Shiloh Broadway
Staff Signature
 

HOHS Executive Director & HSOTC Business Manager

First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
First Participant's Demographics

Race or ethnicity *
Has the participant ever experienced any of the following in their life? Please check all that apply: *
Adult Physical Assault (includes aggravated and simple assault)
Adult Sexual Assault
Adults: Sexually abused/assaulted as a child
Arson
Bullying (verbal, cyber, physical)
Burglary
Child Physical Abuse or Neglect
Child Pornography
Child: Sexual Abuse/Assault
Domestic, Family or Intimate Partner Violence
DUI/DWI Incidents
Elder Abuse or Neglect
Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other
Human Trafficking: Labor
Human Trafficking: Sex
Identity Theft/Fraud/Financial Crime
Kidnapping (non-custodial)
Kidnapping (custodial)
Mass Violence (domestic/international)
Other Vehicular Victimization (hit & run)
Robbery
Stalking/Harassment
Survivors of Homicide Victims
Teen Dating Violence
Terrorism (domestic/international)
Other
Client has not experienced any of these in their life
Does the participant identify as any of the following: *
Immigrant/Refugee/Asylum Seeker
Military Veteran
Homeless
Deaf or Hard of Hearing
LGBTQ+
Person with Disability (Cognitive, Physical, Mental)
Person with Limited English
None of the above
Do you consent to Heart of Horse Sense releasing the above demographics as part of our grant reporting requirement? (We will not share your name.)*
Yes
No
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Race or ethnicity *
Has the participant ever experienced any of the following in their life? Please check all that apply: *
Adult Physical Assault (includes aggravated and simple assault)
Adult Sexual Assault
Adults: Sexually abused/assaulted as a child
Arson
Bullying (verbal, cyber, physical)
Burglary
Child Physical Abuse or Neglect
Child Pornography
Child: Sexual Abuse/Assault
Domestic, Family or Intimate Partner Violence
DUI/DWI Incidents
Elder Abuse or Neglect
Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other
Human Trafficking: Labor
Human Trafficking: Sex
Identity Theft/Fraud/Financial Crime
Kidnapping (non-custodial)
Kidnapping (custodial)
Mass Violence (domestic/international)
Other Vehicular Victimization (hit & run)
Robbery
Stalking/Harassment
Survivors of Homicide Victims
Teen Dating Violence
Terrorism (domestic/international)
Other
Client has not experienced any of these in their life
Does the participant identify as any of the following: *
Immigrant/Refugee/Asylum Seeker
Military Veteran
Homeless
Deaf or Hard of Hearing
LGBTQ+
Person with Disability (Cognitive, Physical, Mental)
Person with Limited English
None of the above
Do you consent to Heart of Horse Sense releasing the above demographics as part of our grant reporting requirement? (We will not share your name.)*
Yes
No
Third Participant's Name

First Name*

Middle Name

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

Race or ethnicity *
Has the participant ever experienced any of the following in their life? Please check all that apply: *
Adult Physical Assault (includes aggravated and simple assault)
Adult Sexual Assault
Adults: Sexually abused/assaulted as a child
Arson
Bullying (verbal, cyber, physical)
Burglary
Child Physical Abuse or Neglect
Child Pornography
Child: Sexual Abuse/Assault
Domestic, Family or Intimate Partner Violence
DUI/DWI Incidents
Elder Abuse or Neglect
Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other
Human Trafficking: Labor
Human Trafficking: Sex
Identity Theft/Fraud/Financial Crime
Kidnapping (non-custodial)
Kidnapping (custodial)
Mass Violence (domestic/international)
Other Vehicular Victimization (hit & run)
Robbery
Stalking/Harassment
Survivors of Homicide Victims
Teen Dating Violence
Terrorism (domestic/international)
Other
Client has not experienced any of these in their life
Does the participant identify as any of the following: *
Immigrant/Refugee/Asylum Seeker
Military Veteran
Homeless
Deaf or Hard of Hearing
LGBTQ+
Person with Disability (Cognitive, Physical, Mental)
Person with Limited English
None of the above
Do you consent to Heart of Horse Sense releasing the above demographics as part of our grant reporting requirement? (We will not share your name.)*
Yes
No
Fourth Participant's Name

First Name*

Middle Name

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

Race or ethnicity *
Has the participant ever experienced any of the following in their life? Please check all that apply: *
Adult Physical Assault (includes aggravated and simple assault)
Adult Sexual Assault
Adults: Sexually abused/assaulted as a child
Arson
Bullying (verbal, cyber, physical)
Burglary
Child Physical Abuse or Neglect
Child Pornography
Child: Sexual Abuse/Assault
Domestic, Family or Intimate Partner Violence
DUI/DWI Incidents
Elder Abuse or Neglect
Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other
Human Trafficking: Labor
Human Trafficking: Sex
Identity Theft/Fraud/Financial Crime
Kidnapping (non-custodial)
Kidnapping (custodial)
Mass Violence (domestic/international)
Other Vehicular Victimization (hit & run)
Robbery
Stalking/Harassment
Survivors of Homicide Victims
Teen Dating Violence
Terrorism (domestic/international)
Other
Client has not experienced any of these in their life
Does the participant identify as any of the following: *
Immigrant/Refugee/Asylum Seeker
Military Veteran
Homeless
Deaf or Hard of Hearing
LGBTQ+
Person with Disability (Cognitive, Physical, Mental)
Person with Limited English
None of the above
Do you consent to Heart of Horse Sense releasing the above demographics as part of our grant reporting requirement? (We will not share your name.)*
Yes
No
Fifth Participant's Name

First Name*

Middle Name

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

Race or ethnicity *
Has the participant ever experienced any of the following in their life? Please check all that apply: *
Adult Physical Assault (includes aggravated and simple assault)
Adult Sexual Assault
Adults: Sexually abused/assaulted as a child
Arson
Bullying (verbal, cyber, physical)
Burglary
Child Physical Abuse or Neglect
Child Pornography
Child: Sexual Abuse/Assault
Domestic, Family or Intimate Partner Violence
DUI/DWI Incidents
Elder Abuse or Neglect
Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other
Human Trafficking: Labor
Human Trafficking: Sex
Identity Theft/Fraud/Financial Crime
Kidnapping (non-custodial)
Kidnapping (custodial)
Mass Violence (domestic/international)
Other Vehicular Victimization (hit & run)
Robbery
Stalking/Harassment
Survivors of Homicide Victims
Teen Dating Violence
Terrorism (domestic/international)
Other
Client has not experienced any of these in their life
Does the participant identify as any of the following: *
Immigrant/Refugee/Asylum Seeker
Military Veteran
Homeless
Deaf or Hard of Hearing
LGBTQ+
Person with Disability (Cognitive, Physical, Mental)
Person with Limited English
None of the above
Do you consent to Heart of Horse Sense releasing the above demographics as part of our grant reporting requirement? (We will not share your name.)*
Yes
No
Sixth Participant's Name

First Name*

Middle Name

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

Race or ethnicity *
Has the participant ever experienced any of the following in their life? Please check all that apply: *
Adult Physical Assault (includes aggravated and simple assault)
Adult Sexual Assault
Adults: Sexually abused/assaulted as a child
Arson
Bullying (verbal, cyber, physical)
Burglary
Child Physical Abuse or Neglect
Child Pornography
Child: Sexual Abuse/Assault
Domestic, Family or Intimate Partner Violence
DUI/DWI Incidents
Elder Abuse or Neglect
Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other
Human Trafficking: Labor
Human Trafficking: Sex
Identity Theft/Fraud/Financial Crime
Kidnapping (non-custodial)
Kidnapping (custodial)
Mass Violence (domestic/international)
Other Vehicular Victimization (hit & run)
Robbery
Stalking/Harassment
Survivors of Homicide Victims
Teen Dating Violence
Terrorism (domestic/international)
Other
Client has not experienced any of these in their life
Does the participant identify as any of the following: *
Immigrant/Refugee/Asylum Seeker
Military Veteran
Homeless
Deaf or Hard of Hearing
LGBTQ+
Person with Disability (Cognitive, Physical, Mental)
Person with Limited English
None of the above
Do you consent to Heart of Horse Sense releasing the above demographics as part of our grant reporting requirement? (We will not share your name.)*
Yes
No
Seventh Participant's Name

First Name*

Middle Name

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

Race or ethnicity *
Has the participant ever experienced any of the following in their life? Please check all that apply: *
Adult Physical Assault (includes aggravated and simple assault)
Adult Sexual Assault
Adults: Sexually abused/assaulted as a child
Arson
Bullying (verbal, cyber, physical)
Burglary
Child Physical Abuse or Neglect
Child Pornography
Child: Sexual Abuse/Assault
Domestic, Family or Intimate Partner Violence
DUI/DWI Incidents
Elder Abuse or Neglect
Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other
Human Trafficking: Labor
Human Trafficking: Sex
Identity Theft/Fraud/Financial Crime
Kidnapping (non-custodial)
Kidnapping (custodial)
Mass Violence (domestic/international)
Other Vehicular Victimization (hit & run)
Robbery
Stalking/Harassment
Survivors of Homicide Victims
Teen Dating Violence
Terrorism (domestic/international)
Other
Client has not experienced any of these in their life
Does the participant identify as any of the following: *
Immigrant/Refugee/Asylum Seeker
Military Veteran
Homeless
Deaf or Hard of Hearing
LGBTQ+
Person with Disability (Cognitive, Physical, Mental)
Person with Limited English
None of the above
Do you consent to Heart of Horse Sense releasing the above demographics as part of our grant reporting requirement? (We will not share your name.)*
Yes
No
Eighth Participant's Name

First Name*

Middle Name

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

Race or ethnicity *
Has the participant ever experienced any of the following in their life? Please check all that apply: *
Adult Physical Assault (includes aggravated and simple assault)
Adult Sexual Assault
Adults: Sexually abused/assaulted as a child
Arson
Bullying (verbal, cyber, physical)
Burglary
Child Physical Abuse or Neglect
Child Pornography
Child: Sexual Abuse/Assault
Domestic, Family or Intimate Partner Violence
DUI/DWI Incidents
Elder Abuse or Neglect
Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other
Human Trafficking: Labor
Human Trafficking: Sex
Identity Theft/Fraud/Financial Crime
Kidnapping (non-custodial)
Kidnapping (custodial)
Mass Violence (domestic/international)
Other Vehicular Victimization (hit & run)
Robbery
Stalking/Harassment
Survivors of Homicide Victims
Teen Dating Violence
Terrorism (domestic/international)
Other
Client has not experienced any of these in their life
Does the participant identify as any of the following: *
Immigrant/Refugee/Asylum Seeker
Military Veteran
Homeless
Deaf or Hard of Hearing
LGBTQ+
Person with Disability (Cognitive, Physical, Mental)
Person with Limited English
None of the above
Do you consent to Heart of Horse Sense releasing the above demographics as part of our grant reporting requirement? (We will not share your name.)*
Yes
No
Ninth Participant's Name

First Name*

Middle Name

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

Race or ethnicity *
Has the participant ever experienced any of the following in their life? Please check all that apply: *
Adult Physical Assault (includes aggravated and simple assault)
Adult Sexual Assault
Adults: Sexually abused/assaulted as a child
Arson
Bullying (verbal, cyber, physical)
Burglary
Child Physical Abuse or Neglect
Child Pornography
Child: Sexual Abuse/Assault
Domestic, Family or Intimate Partner Violence
DUI/DWI Incidents
Elder Abuse or Neglect
Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other
Human Trafficking: Labor
Human Trafficking: Sex
Identity Theft/Fraud/Financial Crime
Kidnapping (non-custodial)
Kidnapping (custodial)
Mass Violence (domestic/international)
Other Vehicular Victimization (hit & run)
Robbery
Stalking/Harassment
Survivors of Homicide Victims
Teen Dating Violence
Terrorism (domestic/international)
Other
Client has not experienced any of these in their life
Does the participant identify as any of the following: *
Immigrant/Refugee/Asylum Seeker
Military Veteran
Homeless
Deaf or Hard of Hearing
LGBTQ+
Person with Disability (Cognitive, Physical, Mental)
Person with Limited English
None of the above
Do you consent to Heart of Horse Sense releasing the above demographics as part of our grant reporting requirement? (We will not share your name.)*
Yes
No
Tenth Participant's Name

First Name*

Middle Name

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

Race or ethnicity *
Has the participant ever experienced any of the following in their life? Please check all that apply: *
Adult Physical Assault (includes aggravated and simple assault)
Adult Sexual Assault
Adults: Sexually abused/assaulted as a child
Arson
Bullying (verbal, cyber, physical)
Burglary
Child Physical Abuse or Neglect
Child Pornography
Child: Sexual Abuse/Assault
Domestic, Family or Intimate Partner Violence
DUI/DWI Incidents
Elder Abuse or Neglect
Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other
Human Trafficking: Labor
Human Trafficking: Sex
Identity Theft/Fraud/Financial Crime
Kidnapping (non-custodial)
Kidnapping (custodial)
Mass Violence (domestic/international)
Other Vehicular Victimization (hit & run)
Robbery
Stalking/Harassment
Survivors of Homicide Victims
Teen Dating Violence
Terrorism (domestic/international)
Other
Client has not experienced any of these in their life
Does the participant identify as any of the following: *
Immigrant/Refugee/Asylum Seeker
Military Veteran
Homeless
Deaf or Hard of Hearing
LGBTQ+
Person with Disability (Cognitive, Physical, Mental)
Person with Limited English
None of the above
Do you consent to Heart of Horse Sense releasing the above demographics as part of our grant reporting requirement? (We will not share your name.)*
Yes
No
Parent or Guardian's Email Address

Email
Check to receive information, news, and opportunities by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
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.


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*

Middle Name

Last Name*

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

Race or ethnicity *
Has the participant ever experienced any of the following in their life? Please check all that apply: *
Adult Physical Assault (includes aggravated and simple assault)
Adult Sexual Assault
Adults: Sexually abused/assaulted as a child
Arson
Bullying (verbal, cyber, physical)
Burglary
Child Physical Abuse or Neglect
Child Pornography
Child: Sexual Abuse/Assault
Domestic, Family or Intimate Partner Violence
DUI/DWI Incidents
Elder Abuse or Neglect
Hate Crime: Racial/Religious/Gender/Sexual Orientation/Other
Human Trafficking: Labor
Human Trafficking: Sex
Identity Theft/Fraud/Financial Crime
Kidnapping (non-custodial)
Kidnapping (custodial)
Mass Violence (domestic/international)
Other Vehicular Victimization (hit & run)
Robbery
Stalking/Harassment
Survivors of Homicide Victims
Teen Dating Violence
Terrorism (domestic/international)
Other
Client has not experienced any of these in their life
Does the participant identify as any of the following: *
Immigrant/Refugee/Asylum Seeker
Military Veteran
Homeless
Deaf or Hard of Hearing
LGBTQ+
Person with Disability (Cognitive, Physical, Mental)
Person with Limited English
None of the above
Do you consent to Heart of Horse Sense releasing the above demographics as part of our grant reporting requirement? (We will not share your name.)*
Yes
No
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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