Dreams Go On with High Hopes
Therapeutic Horseback Riding Program
1006 Valley View Boulevard
Altoona, PA 16602
REGISTRATION AND RELEASE FORM
Rider Name: __________________________________________________________
Date of Birth: _________________________________________________________
Address: _____________________________________________________________
Phone(s): _____________________________________________________________
E mail address: ________________________________________________________
Parent(s)/Guardian: _____________________________________________________
School Presently Attending: ______________________________________________
Rider’s Medical Insurance Company: _______________________________________
Insurance #: ___________________________________________________________
Liability Release
_____________________________ (Rider’s name) would like to participate in Dreams Go On
and I acknowledge and understand the risks and potential of risks of horseback riding. However,
I feel that the possible benefits for myself/son/daughter/ward are greater than the risks assumed.
I hereby, intending to be legally bound, for myself, my heirs and assigns, executors, or
administrators, waive and release forever all claims for damage against Dreams Go On, its Board
of Directors, Instructors, Volunteers, Therapists, Members, Owners of equines, and owners or
employees of the stable for any and all injuries and losses I/my son/daughter/ward may sustain
while participating.
Signature of Rider (if over 18): ____________________________________________
Signature of Parent or Guardian: ___________________________________________
Date: _________________________________________________________________
Registration and Release Form
Photo Release
I hereby consent to authorize the use and reproduction by Dreams Go On of any and all
photographic and audiovisual material taken of me/my son/my daughter/my guardian for
promotional purposes, educational activities, exhibitions or any other use for the benefit
of the program.
Signature of Rider (if over 18): ______________________________________________
Signature of Parent or Guardian: ____________________________________________
Date: __________________________________________________________________
Pennsylvania Equine Liability Law:
You assume the risk of Equine Activities pursuant to Pennsylvania Law. 2005
Rider/Parent, please send this printed and filled out form to:
Debbie Kelly, Rider Coordinator
1006 Valley View Blvd
Altoona, PA 16602
Form Version Feb. 18, 2008