Parent/Guardian

Parent/Guardian Name

Street

City

Zip

Home Phone:

Cell

Email

 

In Case of Emergency

Contact

Relation

Phone

Contact

Relation

Phone

Beyond Limits Therapeutic Riding, Inc., (BLTR) its officers, members, employees, instructors (Kristen Moreland, Kristina Meyer, and Kingsley Sawtelle) and agents (including other riders) will not be responsible for any damages to person, animal or property at the BLTR riding facility or its grounds or at any BLTR activities at other locations. Nor will BLTR be responsible for any property lost, damaged or destroyed. The undersigned rider and/or volunteer or parent/guardian hereby releases BLTR, its officers, members, employees, instructors and agents from ANY and ALL liability and claims of any nature whatsoever including taking any action to control, restrain, or confine the undersigned, for the safety or protection of the undersigned or others and any damages whatsoever (including costs, expenses and attorney’s fees) that might result from damages, injuries or losses to their person or property during, or in connection with, or arising out of any volunteer activities, rider work, class, lesson, demonstration, show, clinic, event, function or any activity whatsoever, whether or not such damages, injuries or losses result directly or indirectly from the negligent act or omission or of any intentional or willful act or tort of such released parties or of any invitee of any released party.

WARNING: UNDER GEORGIA LAW, ANY EQUINE ACTIVITY SPONSOR OR EQUINE ACTIVITY PROFRESSONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE OR ANIMAL ACTIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES, PURSUANT TO CHAPTER 12 OF TITLE 4 OF THE OFFICAL CODE OF GEORGIA ANNOTATED.

I have read and understand the Georgia Equine Liability Law. I agree that my use of the premises, and any animals, facilities or equipment is at my OWN risk. I further agree to indemnify and hold harmless BLTR, its respective officers, any and all property owners, employees, volunteers and tenants harmless from any and all suits, actions, costs, claims and liabilities of any kind arriving out of my use of the facility, premises, or participation in an equine activity, any animal activities at the facility or at another location with facility animals, any horse, dog, pony, cat, or animal on the property, living at visiting or boarding at the facility or of such use or participation by my guest, whether or not such claims result directly or indirectly from negligent act or omissions of the indemnified parties or otherwise. As a consideration for my visiting the facility or any BLTR Inc. activities at other locations, I assume any risk of damage to property, animal, injury or death to myself, or anyone visiting the facility with me. I understand there are certain risks inherent with handling animals and I accept those risks. I also acknowledge that horseback riding, and any involvement with horses, is a high-risk activity. I am participating at my own risk. I have read this agreement and fully understand its content.

 

Release of Liability AGREED:

For valuable consideration given and which is hereby acknowledged, the undersigned hereby grants BLTR permission to take, or have taken, still and moving photographs and films of the above named Participant, including television pictures, and consents and authorizes BLTR, its advertising agencies, news media, and any other persons interested in BLTR and its work, to use and reproduce the photographs, films or pictures, and to circulate and publicize the same by all means, including, without limiting the generality of the foregoing, newspapers, television media, brochures, pamphlets, instructional materials, books, and clinical materials. With respect to the foregoing matters, no inducements or promises have been made to secure this signature to this release other than the intention of BLTR to use, or cause to be used, such photographs, films, and pictures for the primary purpose of promoting BLTR and its work.

   

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 Beyond Limits Therapeutic Riding, Inc. to:

1. Secure and retain medical treatment and transportation if needed.
2. Release participant records upon request to the authorized individual or agency involved in the emergency medical treatment at my expense.

I hold Beyond Limits Therapeutic Riding, Inc. harmless for any expenses incurred in my interests.

CONSENT PLAN (to be invoked in the event that your Emergency Contact cannot be reached) I give consent for emergency medical treatment/aid (including x-ray, surgery, hospitalization, medication, and any treatment procedure deemed “lifesaving” by the physician) in the event of illness or injury while on the property of the agency. The undersigned hereby agrees to pay all fees and expenses of doctors, hospitals, ambulances and any other medical or dental expenses incurred.

 

Consent Signature:

 

Non-Consent Signature:

Health History I give my permission for Beyond Limits Therapeutic Riding, Inc. staff to give allergy medicine (such as Benadryl) to my child, if they are exhibiting signs of an allergic reaction to the horses or the stable environment.  

I hereby authorize Beyond Limits Therapeutic Riding, Inc. to release information from the records of Participant for the purpose of developing a Riding Program for the above-named participant. The information to be released is indicated below.

 

For Persons with Down Syndrome:

 

Please check if patient has a problem or surgeries in any of the following. If yes, please comment.

 

Mobility

Independent Ambulation

Yes No

Crutches

Yes No

Braces

Yes No

Wheelchair

Yes No

Referral for Therapeutic Horseback Riding

This is a referral for evaluation and treatment by a Therapeutic Riding Instructor, or mental health professional in conjunction with Beyond Limits Therapeutic Riding, Inc. Recommended Therapeutic Riding Program Frequency to be determined by Riding Instructor:

Precautions
________________________________________________________________________________________________________________________

Physician’s Signature:____________________________________________________________ Date:_________________________

 

Please Print, Type or Stamp Physician’s

Name _______________________________________________________________

Address _____________________________________________________________

Phone _________________________ Fax _________________________
 

To my knowledge there is no reason why this person cannot participate in supervised equestrian activities. However, I understand that the therapeutic riding center will weigh the medical information above against the existing precautions and contraindications. I concur with a review of this person’s abilities/limitations by a Therapeutic Riding Instructor in the implementing of an effective equestrian program.

Physician Name (please print) _______________________________________________________________

Physician Signature _______________________________________________________________

Address _________________________________________________ City _________________________ State ______ Zip ____________

Phone _________________________ Date _________________________
 

 

This policy is to be used as a payment plan for services at Beyond Limits Therapeutic Riding. Monthly tuition includes weekly or bi-weekly therapeutic riding lessons at a length agreed upon by client and a Beyond Limits Certified instructor. 
Tuition: Tuition for each month is due on the first of the month. Payment will include weekly or bi-weekly lessons based on how many weeks during the month the rider is scheduled. If the rider must cancel due to travel or illness, and they do so greater than 24 hours in advance, they will have the opportunity to make up the lesson within 30 days without penalty or loss of lesson. If there is no opportunity to makeup the therapeutic lesson within the 30 day expiration date, then payment will be forfeited. 

• Invoices will be sent out prior to the first of the month and can be paid online via our website, by check payable to Beyond Limits, or by cash brought to the barn. Please make sure we have a valid email address for your family.
• Please do not show up at the barn without payment as we do not enjoy telling riders they can’t ride

             Fees: 1 hour weekly Therapeutic Riding Lesson - $70 per lesson x number of weeks in month
                       1 hour weekly TR Lesson if on own horse - $35 per lesson x number of weeks in month
                      45 min weekly Therapeutic Riding Lesson - $55 per lesson x number of weeks in month
                      30 min weekly Therapeutic Riding Lesson - $40 per lesson x number of weeks in month

Lesson Schedules: Lessons are currently available Tuesday-Friday every week. The schedule is based on rider availability, instructor availability, and horse use. It will be finalized on Sundays by 5:00pm. Any schedule changes for the week need to be requested before then. If illness occurs please reach out to your instructor greater than 24 hours before your therapeutic lesson is to take place. If you do not communicate with your instructor before the 24 hour time frame you will be considered a ‘late cancel’ and may not be able to make-up the therapeutic lesson. 

No Shows: If you fail to communicate to your instructor that you will be unable to attend your lesson, you will forfeit the lesson. No make-up will be rescheduled. Please be respectful of the instructor's time, the volunteer’s time, and the horse’s time. Instructors and volunteers plan their day and schedules to be there for you, please keep that in mind and be conscientious of their time and dedication to your rider. 

Makeup Lessons: Make-up lessons are available to those who communicate their schedule changes before the Sunday at 5:00pm deadline for the week, or with the 24 hour cancel for illness. Riders will have 30 days to make up the missed lesson before it will be forfeited. We will do our best to get the makeup lesson scheduled as soon as possible depending on rider, instructor, and horse availability. Please understand that regularly scheduled lessons get horse priority. Therefore, you may not have your riders usual horse for the makeup lesson, however it will still be a mount appropriate for your rider’s skill level and needs. If you have a ‘no show’ or a ‘late cancel’ for a lesson, a make-up lesson may not be given and you will forfeit your lesson for that week. 

Weather/Rain: Inclimate weather is not an excuse to cancel a therapeutic lesson. If inclement weather prevents us from riding, and the indoor riding arena is unavailable, we will have a horse care and management lesson inside in lieu of riding. These lessons will be held inside the barn, out of the weather, and will give the rider opportunity to bond with their horse, and learn valuable lessons in horse care and how they can be applied to their life outside the barn. In cases in which a horse management lesson is to be held, diagnosis is also not a valid reason to cancel. We understand every rider has a different diagnosis, and some more involved than others, but each individual will benefit from these horse care and therapeutic lessons, as they will be tailored to the individuals needs, just as the therapeutic riding lessons are. 
 
*In extreme instances where it would be deemed unsafe to travel to the barn (snow/tornado watch) then lesson cancellations will be communicated by the instructor and makeups will be scheduled with no penalty. Do not assume lessons are cancelled however and communicate with the instructor first. 

We hope to be able to improve our quality of service by implementing this new policy. Reducing the number of cancellations will allow more consistency to therapeutic riding participants, improving their strength and skills. The implementation of the new horse management option will allow us to grow riders beyond the arena and give them the tools to be successful equestrians, and better stewards of their mounts, from the ground up. 
 
The indoor horse management lessons include all riders. Participants who have payment assistance through outside organizations, including but not limited to; Highland Rivers, Kaleidoscope, Georgia Community Foundation, and Pathways are expected to attend all scheduled therapeutic lessons as well, whether in the saddle on or on the ground, as therapeutic benefits can be seen from both options.
 
We look forward to continuing our partnership with your family and seeing the amazing growth in your riders through our Therapeutic Riding activities. We are excited you are with us as we Grow Beyond together! 

I have read and agree to the stated fee chart above. I understand if I cancel less than 24 hours from my appointment time I will be billed half the cost of my scheduled lesson.
 

   

If an outside source is paying for Therapeutic Riding Lessons please list them below: