LIABILITY RELEASE 

Crossroads Foundation, Inc. Ball Ground, GA. 30107

Winds of Change Programs, Discovery Tracks, VIP Program and Trail Blazers Programs 

WARNING

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

 

I have read and understand the Georgia Equine Liability Law.  I shall hold Crossroads Foundation, Inc. (A.K.A. the facility), owners, employees and tenants harmless from any and all costs, claims and liabilities of any kind arriving out of my use of the facility, any equine activities, any horse, pony or animal on the property, living at, visiting or boarding at the facility.  As a consideration for my visiting the facility I assume any risk of damage to property, animal or injury to myself, or anyone visiting the facility with me.  I understand horses and other animals can bite, strike, etc, which can cause injury or death. 

 

Print Child's Name________________________________

Signature of child________________________________

Parent or Guardian Signature _____________________________

Address:______________________________________________________________________________________________________________

 

Phone:__________________________

 

Emergency Contact Name ____________________________________

Phone number:______________________________

  

Reason Why You Are At This Facility: (circle one)

    

Volunteer                     Visitor              Community Service                   Summer Program

 

 

 

Crossroads Foundation, Inc.

MEDICAL INFORMATION AND RELEASE FORM

 

            If medical care is required for __________________ (name of participant) in conjunction with any Crossroads Foundation, Inc. activity or related transportation, and if normal permission is not available in a timely manner, the undersigned authorizes appropriate medical care as deemed necessary by emergency medical personnel, a physician and/or the medical facility providing treatment.

 

RELATED INFORMATION

 

Name____________________________                    Home Phone: __________________

Address: __________________________________

Work Phone: __________________                Cell Phone: ____________________

Emergency Contact: ________________________         Phone:______________________

Family Physician: ___________________________       Phone:______________________

I am allergic to:  _______________________________________________________

Other medical conditions:___________________________________________

I am taking the following medications_________________________________________

________________________________________               

For: _________________________

Date of birth: ________________________

Medical insurance company: ___________________              

Policy Number(s): _______________

 

SPECIAL INSTRUCTIONS

 

            If I am injured and need medical help, please attempt to contact my emergency contact at the time of the accident or illness without postponing medical treatment.

I HAVE READ THIS ENTIRE RELEASE AND AGREE TO IT:

 

____________________________

V I P Attendee

 

____________________________               

                        Date

 

____________________________

Witness Signature