THRIVE PROGRAM INFORMATION

THRIVE is a program that mentors adolescent girls ages 11-18 through character building in the areas of relationship, horsemanship and responsibility.  It facilitates emotional growth in relationships by instilling in the

girls a sense of integrity and value through experiential learning with horses.  The program runs concurrent with the school year and meets weekly.

Truth – helps girls to live in freedom. Believing “if you continue in my word…then you will know the truth, and the truth will set you free.” (John 8:31-32). Truth says, “You are free.”

Horsemanship – empowers girls to be honest, engaged, caring, trustworthy, and to work hard for what they want.  Horsemanship teaches skills in riding and horse care, but more importantly, it teaches girls about themselves and the relationships they create.  Horsemanship says, “You are responsible.”

Relationship – heals the deepest wounds of the heart that are caused by brokenness in relationship.  Relational skills and concepts can be “re-learned” through experiences with horses, and then transferred in relationships with peers and adults.  Healing in family relationships are encouraged through family counseling and equine-assisted activities.  Relationship says, “You are loved deeply.”

Integrity – builds healthy character through consistent actions, values, principles and follow-through.  We want our girls to do the right thing because they believe it is the right thing to do!  Integrity says, “You can trust me.”

Value – is the inherent worth of every person.  What we believe about ourselves determines our decisions and behavior.  This impacts everything in our lives!  Those who believe that they have true value as people are able to rest from seeking value and acceptance from others.  Value says, “You have great worth.”

Experience – teaches by doing and enables girls to discover new possibilities.  With the horses, girls learn to take risks and deal with success and failure, to work together, problem solve and make decisions.  Experience says, “You can do it!”

Philosophy

Cross Keys Equine Therapy believes that there is no such thing as an inherently bad youth and that if one is headed the wrong direction, he/she needs to be given a chance to see another way of life and an opportunity to learn constructive attitudes.

We seek to encourage participants to take ownership of truths in their lives by allowing horses to teach them how to be authentic, present, how to seek open and honest communication with others, and how to take care of themselves by giving and receiving trust and respect.

Vision

Cross Keys Equine Therapy’s vision for the THRIVE program is that the adolescent girls in the program will be transformed by experiencing love, relationships, and identity in Christ.

Mission

The mission of the THRIVE program is to provide adolescent girls guided interaction with horses to facilitate the development of character and interpersonal skills in a Christ-centered environment.

Beliefs

We believe that healing is made possible only by the grace of God.We believe the Bible is the word of God and is our source of truth.We believe that behavior is only a symptom of what is going on in the heart.We believe that passivity is one of the greatest difficulties of our existence and that heart change requires active pursuit of truth.

Parental Involvement

As a parent with a daughter involved in THRIVE, your commitment and support is essential to your child’s success in the program. Please understand the time commitment, as we have many staff and volunteers that have dedicated their time to working with your daughter. While THRIVE is a program that is provided completely free of charge to your daughter, if she is going to miss one of the sessions, it is important that you contact us as soon as possible, at (540) 607-6910, or through email at crosskeysequinetherapy@gmail.com

The Value/Role of the Horse

Horses have a unique ability to respond to a person’s behaviors and emotional state without regard for physical appearance, social or financial status, intelligence, or accomplishments. They require that a person be engaged with them, and do not allow themselves to be manipulated. As a result, horses can create opportunities for Participants to identify their fears, patterns of behavior that hinder relationships, and ineffectual communication habits.

Session ComponentsCKET uses a variety of activities including, but not limited to, equine assisted interventions, in order to mentor the Participant. Equine assisted interventions include both riding and non-riding activities. Other activities in this program include grooming, chores, crafts and games.

Mentors

Program mentors aim to conduct themselves with professionalism, transparency and accountability while fostering relationships that are open and authentic.

Medication

If your child needs to take medication during the THRIVE time frame, please inform the Director.

Attendance

Your child should be at THRIVE on the proper days unless they are sick. If your child did not go to school due to sickness, then please do not bring them to THRIVE. When unexpected situations occur that prohibit your attendance, please contact the Director or your daughter’s mentor as soon as possible, preferably 24 hours in advance of your session.

Closings

1) All scheduled closings will be announced via email/text or phone call.

2) Closings due to snow or inclement weather will follow the Rockingham County Public School system. If school is closed, so are we. If students have an early dismissal, we will not have THRIVE.

Participant Dress Code

1) Clothes must be neat and appropriate. Revealing shirts such as thin strapped tank tops and low cut shirts will not be allowed. Be advised of the probability that clothes and shoes may get dirty and/or be damaged. Recommended clothing: jeans/long pants, t-shirts, sweaters, **Please bring warm layers as it gets cold and sometimes weather is unpredictable.2) Required footwear: boots and/or tennis shoes.

Participant Conduct Code

1) Items NOT allowed: cell phones, electronic devices, knives, matches, lighters, or anything that could be used as weapons. If any of these items are brought to CKET, they must be given to the staff for safe keeping during the THRIVE event. If weapon-like items are brought to CKET, they may be taken away permanently. 2) CKET is a smoke-free and drug-free farm. 3) All Participants are expected to respect authority, their peers, CKET animals and property in general. 4) All Participants are expected to accept consequences for their behaviors and do what is asked of them, without complaining, arguing or fussing. 5) If a Participant threatens to do harm to CKET staff, peers, volunteers, animals or property in general AND/OR if a Participant runs away from the farm, the police will be called and charges will possibly be filed against the Participant. 6) Farm chores are a part of the THRIVE program. These chores include, but are not limited to, mucking stalls/paddocks, feeding the animals, cleaning tack, and general barn/yard maintenance.

Your Responsibilities

A personal commitment to THRIVE is crucial for your success. It is important that you be involved, open, and honest with group facilitators, other participants, and yourself. Attendance is vital to the group process. Your absence affects not only your own growth but the growth of the other participants. Progress each week builds on what has been accomplished in previous sessions. The group process and your personal growth could be impacted by non-attendance.

It is your responsibility to tell the group facilitators when you are uncomfortable with any parts of the THRIVE program. This will promote your personal safety, the safety of other participants, and the horses.

Coordination with Other Services

If you are receiving treatment from an outside mental health professional, it is important for us to communicate and coordinate services to best serve you. Additionally, CKET requests permission to communicate with school personnel. For this reason we request that you sign an exchange of information for both the outside mental health professional and school personnel.

Contacting Us

We are often not immediately available by telephone. We do not answer calls while we are with Participants or otherwise unavailable. At these times, you may leave a message and your call will be returned as soon as possible. For non-urgent matters, this may take up to 48 hours. We are unable to provide crisis services – If at any time you feel that there is imminent risk to yourself or to someone else, call 911 immediately . Outside the operating hours of THRIVE, we do not provide crisis services but we can direct you to the appropriate supports. In the event that you have received outside crisis support, such as hospitalization or a crisis evaluation, please let us know. Informing us of these circumstances will help us support you in the best way possible.

Email

If you choose to contact CKET via email, text or social media, please understand that we cannot guarantee the confidentiality of information communicated in this manner. All emails, texts, posts/messages are retained in the logs of the service providers. While under normal circumstances no one looks at these logs, they are, in theory, available to be read. By choosing to contact CKET via text, email or social media, you agree to allow mutual communication via these methods.

THRIVE APPLICATIONPLEASE FILL IN AS COMPLETELY AND ACCURATELY AS POSSIBLE

 Date:

Name of Applicant: DOB: Age: _

Address:

City: State: Zip:

Parent/Guardian Names:

Home Phone: Email:

Cell Phone: Business Phone:

May we leave a message at home? o  Yes  o  No May we leave a message at work? o  Yes  o  No Parental Status: o  Single   o  Married    o  Separated    o  Divorced    o  Widowed Other people living in your home:Name Relationship  DOB

Age

What goals do you have for your child’s participation in THRIVE?

Is there anything you would like us to know about your child?

Has your child (check all that apply):

Physically harmed another individual, pet, or small animal? Received medication in the past for emotional, learning, or behavioral problems? Run away from home? Started a fire? Talked about or attempted suicide? Threatened to physically harm anyone? None of the above

Comments:

Activities of Daily Living

Check areas of difficulty your child displays when performing daily activities:

Adapting to Changes Attending to/Completing tasks Decision Making Following a Routine Goal Setting Problem solving Performing self-care (hygiene, bathing, etc.) Other: None of the above

Comments:

Please describe your child’s activities outside of the home (hobbies, sports, volunteer activities, etc.):

Social Support/Peer Interactions

Please describe your view of your child’s social support/peer interactions/ability to make and keep

friends:

Strengths/Assets:

Please describe your child’s strengths/assets:

By signing this form, I, ________________________________________ (please print parent/guardian/ adult client

name) certify all information to be complete and true to the best of my knowledge.

Client’s signature (if over 18) Date

Parent/Guardian Signature Date

MEDICAL HISTORY AND EMERGENCY INFORMATION

Client’s Full Name:_____________________________________________ Date of Birth:___________________

Height:____________ Weight:_____________ Tetanus Shot: Y[ ] N[ ]

Medications & Dosage Taken Since Prescribed by (Physician)

_____________________________________________ _________________ _________________________

_____________________________________________ _________________ _________________________

_____________________________________________ _________________ _________________________

Please check any areas of medical concern. If “yes,” please explain in the Comments section

Yes No CommentsAuditory _________________________Visual _________________________Speech _________________________Cardiac _________________________Circulatory _________________________Pulmonary _________________________Neurological _________________________Muscular _________________________Orthopedic _________________________Allergies/Asthma _________________________Learning Disability _________________________Psychological Impairment _________________________Diabetes _________________________Drug allergy/reactions _________________________Other____________________ _________________________

Any diet restrictions or food allergies?

Parent/Guardian: Phone #:

*1st Emergency Contact: Relationship to Client: Phone #: *2nd Emergency Contact Relationship to Client: Phone #:

Patient’s Primary Physician: Phone #:

Preferred Medical Facility:

Emergency Medical Consent

The undersigned hereby grants to any Cross Keys Equine Therapy affiliate/employee/intern/volunteer the authority to receive information pertaining to the emergency health care of the client named below and to make emergency health care decisions with respect to the client if the undersigned is unavailable to obtain such information or make such decisions.

Client's Name: Phone #:

Address:

Date: Signature: (parent, guardian, or adult client)

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Emergency Medical Non-Consent

If the undersigned does not desire to grant any Cross Keys Equine Therapy affiliate/employee/intern/volunteer information or to make health care decisions for the client if the undersigned is unavailable, please initial on the line below and state the procedures to be followed if the client becomes ill or is involved in an accident and the undersigned is unavailable.

_____ I Do Not Consent to any Cross Keys Equine Therapy affiliate/employee/intern/volunteer obtaining health care information or making emergency health care decisions concerning the client.

Procedures to be followed:

Date: Signature: (parent, guardian, or adult client)

EQUINE ASSISTED GROWTH & DEVELOPMENT SERVICES AGREEMENT

LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT

READ CAREFULLY AND COMPLETE ALL SECTIONS BEFORE SIGNING

A. Registration of Client and Agreement Purpose. I, the following listed individual (hereinafter referred to as “Client”), and the parents or legal guardians thereof if a minor, do hereby voluntarily agree to participate in Equine Assisted Growth and Development Services, hereinafter referred to as EAGDS, as a client of Cross Keys Equine Therapy (hereinafter referred to as “Provider”), and that I will either utilize my own horse or horse provided by this Provider for EAGDS purposes.

a. Client Name: b. Age (if under 18): c. Date of Birth: d. Weight (over 240 lbs?) YES NO (Circle One)e. Horse Handling Experience:

i. Beginner (Under 10 Hours) ii. Over 10 Hours

f. Does this client have any physical or mental condition(s), which may affect his/her safety and ability to ride, drive, train and/or be near a horse? YES NO (Circle One)

g. If you circled YES, how can we help this client with his/her special needs?

h. Medical Insurance: I/We agree that: Should medical treatment be required, I and/or my medical insurance company shall pay for ALL such incurred expenses.

i. My medical insurance company is: ii. My policy number is

iii. I do not carry medical insurance (Indicate here)B. Agreement Scope and Territory Conditions. This agreement shall be legally binding upon me the registered Client, and the

parents or legal guardians thereof if a minor, my heirs, estate, assigns, including all minor children, and personal representatives; and it shall be interpreted according to the laws of the state and county of this Provider’s physical location. This agreement is intended to be valid and binding at all times now and in the future when this Provider permits me (directly or indirectly) to enter this Provider’s property, be on this Provider’s property, be near any horse, receive riding, driving and/or training instruction or guidance from its associates and/or when I ride, drive, train and/or am near horses on or off this Provider’s property. Any disputes by the Client shall be litigated in, and venue shall be in the county in which this Provider is physically located. This agreement is intended to be as broad and inclusive as the law permits. If any clause, phrase or word is in conflict with state law, then that single part is null and void. The terms “Horse” and “Equine” shall refer to all equine species. The terms “I”, “we”, “me”, “my” shall herein refer to the above registered Client and the parents or legal guardians thereof if a minor.

C. Inherent Risks/Assumption of Risks. I/We acknowledge that: Risks, conditions, and dangers are inherent in (meaning an integral part of) horse/equine/animal activities, regardless of all feasible safety measures which can be taken, and I agree to assume them. The inherent risks include, but are not limited to any of the following: The propensity of an animal to behave in ways that may result in injury, harm, death, or loss to persons on or around the animal; the unpredictability of an equine’s reaction to sounds, sudden movement, unfamiliar objects, persons, or other animals; hazards including, but not limited to, surface or subsurface conditions; a collision, encounter and/or confrontation with another equine, another animal, a person, or an object; the potential of an equine activity participant to act in a negligent manner that may contribute to injury, harm, death, or loss to the participant or to other persons, including but not limited to, failing to maintain control over an equine and/or failing to act within the ability of the Participant. Horses are 5 to 15 times larger, 20 to 40 times more powerful, and 3 to 4 times faster than a human. If a rider falls from a horse to ground it will generally be at a distance of from 3-1/2 to 5-1/2 feet, and the impact may result in hard to the rider. Horseback riding, driving and training are activities in which one much smaller, weaker predator animal (the human) tries to impose its will on, and become one unit of movement with, another much larger, stronger prey animal that has a mind of its own (the horse) and each has a limited understanding of the other. If a horse is frightened or provoked, it may divert from its training and act according to its natural survival instincts which may include, but are not limited to: stopping short; spinning around; changing directions and/or speed at will; shifting its weight; bucking; rearing; kicking; biting; and/or running from danger. I also acknowledge that these are just some of the risks and I agree to assume others not mentioned above. I am not relying on this Provider to list all possible risks for me.

D. Conditions of Nature Warning, Unfamiliar and Sudden Sights, Sounds and Movements Warning, and Inspection of Premises. I/We acknowledge that: this Provider is NOT responsible for total or partial acts, occurrences, or elements of nature and/or sudden and/or unfamiliar sights, sounds and/or sudden movements that can scare a horse, cause it to fall, or react in some other unsafe way. Some examples are: thunder, lightening, rain, wind, wild and domestic animals, insects, reptiles which may walk, run or fly near, or bite or sting a horse or person; and irregular footing on out-of-door groomed or wild land which is subject to constant change in condition according to weather, temperature, and natural and man-made

changes in landscape. I also understand that these are just some of the risks and I agree to assume others not mentioned above. I am not relying on this Provider to list all possible conditions for me. The Client and parent or legal guardian have inspected this Provider’s facilities and are satisfied that all premise conditions are reasonably safe for this client’s intended purpose, usage and presence upon this Provider’s premises.

E. Saddle Girths/Natural Loosening Warning. I/We acknowledge that: Saddle girls (fastener straps around horse’s belly) may loosen during riding. Clients must alert this Provider or their instructor or attendant of any girth looseness so that action can be taken to avoid slippage of saddle and the potential for the rider to fall from the horse.

F. Protective Headgear/Helmet Warning. I/We agree that: for myself and on behalf of my child and/or legal ward have been fully warned by this Provider that protective headgear/helmet, which meets or exceeds the quality standards of the SEI CERTIFIED ASTM STANDARD F 1163 Equestrian Helmet, should be worn while riding, driving, training and being near horses, and I understand the wearing of such headgear/helmet at these times may reduce severity of some of the wearer’s head injuries and possibly prevent the wearer’s death from happening as the result of a fall or other occurrences.

G. Liability Release. I/We agree that: In consideration of this Provider allowing my participation in this EAGDS activity, under the terms set forth herein, I, the Client, for myself and on behalf of my child and/or legal ward, heirs, administrators, personal representatives or assigns, do agree to release, hold harmless, and discharge this Provider, its owners, agents, employees, officers, directors, representatives, assigns, members, owners of premises and trails, affiliated organizations, and Insurers, and others acting on their behalf (hereinafter, collectively referred to as “Associates”), of and from all claims, demands, causes of action and legal liability, whether the same be known or unknown, anticipated or unanticipated, due to this Provider’s and/or its Associates ordinary negligence or legal liability; and I do further agree that except in the event of this Provider’s gross negligence and/or willful and/or wanton misconduct, I shall not bring any claims, demands, legal actions and causes of action, against this Provider and its Associates as stated above in this clause, for any economic and non-economic losses due to bodily injury and/or death and/or property damage, sustained by me and/or my minor child or legal ward I relation to the premises and operations of this Provider, to include while riding, driving, training, handling, or otherwise being near horses owned by me or owned by this Provider, or in the care, custody or control of this Provider, whether on or off the premises of this Provider, but not limited to being on this Provider’s premises.

H. Equine Activity Liability Act (EALA) Warning or Language. [This clause applies only for operations located in these states: AL, AZ, CO, DE, FL, GA, IL, IA, IN, KY, KS, LA, ME, MA, MI, MS, MO, NE, NC, OH, OK, OR, PA, RI, SC, SD, TX, TN, UT, VA, VT, WV, and WI.] I/We acknowledge that: I have reviewed this state’s EQUINE ACTIVITY LIABILITY ACT WARNING OR LANGUAGE, a copy of which is attached hereto and incorporated as if fully set forth herein. INSTRUCTION TO SIGNERS: DO NOT SIGN UNLESS A COPY OF THE EALA WARNING OR LANGUAGE IS ATTACHED TO THIS AGREEMENT.

All Clients and Parents or Legal Guardians must sign below after reading this entire document.

SIGNER STATEMENT OF AWARENESS:I/WE THE UNDERSIGNED, REPRESENT THAT I/WE HAVE READ AND DO UNDERSTAND THE FOREGOING AGREEMENT,

LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT. I/WE UNDERSTAND THAT BY SIGNING THIS DOCUMENT I AM GIVING UP RIGHTS TO SUE TODAY AND IN THE FUTURE. I/WE ATTEST THAT ALL FACTS ARE TRUE AND ACCURATE. I AM SIGNING THIS WHILE OF SOUND MIND AND NOT SUFFERING FROM SHOCK OR UNDER THE INFLUENCE OF ALCOHOL,

DRUGS OR INTOXICANTS.

Signature of Client Date

Signature of Parent/Legal Guardian DateAnd/or Spouse #1

Signature of Parent/Legal Guardian DateAnd/or Spouse #2

Address:

Home Phone:

Cell Phone:

Person to Contact in Case of Emergency:

Relationship to Client: Phone Number:

EQUINE ACTIVITY LIABILITY ACT (EALA)Summary: This Virginia section provides that an equine activity sponsor, an equine professional, or any other person shall not be liable for an injury to or death of a participant resulting from the intrinsic dangers of equine activities.  Liability is not limited where the equine professional intentionally injures the participant, commits an act or omission that constitutes negligence for the safety of the participant, or knowingly provides faulty equipment or tack that causes injury.  The statute seems to imply that a waiver should be executed when a participant engages in equine activities to adequately insulate the equine professional.

Statute TextChapter 62. Equine Activity Liability § 3.2-6200 . Definitions§ 3.2-6201 . Horse racing excluded§ 3.2-6202 . Liability limited; liability actions prohibited§ 3.2-6203 . Liability of equine activity sponsors, equine professionals Chapter 62. Equine Activity Liability § 3.2-6200. Definitions As used in this chapter, unless the context requires a different meaning:"Engages in an equine activity" means: (i) any person, whether mounted or unmounted, who rides, handles, trains, drives, assists in providing medical or therapeutic treatment of, or is a passenger upon an equine; (ii) any person who participates in an equine activity but does not necessarily ride, handle, train, drive, or ride as a passenger upon an equine; (iii) any person visiting, touring or utilizing an equine facility as part of an event or activity; or (iv) any person who assists a participant or equine activity sponsor or management in an equine activity. The term "engages in an equine activity" does not include being a spectator at an equine activity, except in cases where the spectator places himself in an unauthorized area and in immediate proximity to an equine or equine activity."Equine" means a horse, pony, mule, donkey, or hinny."Equine activity" means: (i) equine shows, fairs, competitions, performances, or parades that involve any or all breeds of equines and any of the equine disciplines, including dressage, hunter and jumper horse shows, grand prix jumping, three-day events, combined training, rodeos, driving, pulling, cutting, polo, steeple chasing, endurance trail riding and western games, and hunting; (ii) equine training or teaching activities; (iii) boarding equines; (iv) riding, inspecting, or evaluating an equine belonging to another whether or not the owner has received some monetary consideration or other thing of value for the use of the equine or is permitting a prospective purchaser of the equine to ride, inspect, or evaluate the equine; (v) rides, trips, hunts, or other equine activities of any type however informal or impromptu that are sponsored by an equine activity sponsor; (vi) conducting general hoofcare, including placing or replacing horseshoes or hoof trimming of an equine; and (vii) providing or assisting in breeding or therapeutic veterinary treatment."Equine activity sponsor" means any person or his agent who, for profit or not for profit, sponsors, organizes, or provides the facilities for an equine activity, including pony clubs, 4-H clubs, hunt clubs, riding clubs, school-and college-sponsored classes and programs, therapeutic riding programs, and operators, instructors, and promoters of equine facilities, including stables, clubhouses, ponyride strings, fairs, and arenas where the activity is held."Equine professional" means a person or his agent engaged for compensation in: (i) instructing a participant or renting to a participant an equine for the purpose of riding, driving, or being a passenger upon an equine; or (ii) renting equipment or tack to a participant."Intrinsic dangers of equine activities" means those dangers or conditions that are an integral part of equine activities, including: (i) the propensity of equines to behave in ways that may result in injury, harm, or death to persons on or around them; (ii) the unpredictability of an equine's reaction to such things as sounds, sudden movement, and unfamiliar objects, persons, or other animals; (iii) certain hazards such as surface and subsurface conditions; (iv) collisions with other animals or objects; and (v) the potential of a participant acting in a negligent manner that may contribute to injury to the participant or others, such as failing to maintain control over the equine or not acting within the participant's ability."Participant" means any person, whether amateur or professional, who engages in an equine activity, whether or not a fee is paid to participate in the equine activity.Acts 2008, c. 860, eff. Oct. 1, 2008.HISTORICAL AND STATUTORY NOTESDerivation:Acts 1991, c. 358; Acts 2003, c. 876; § 3.1-796.130.

§ 3.2-6201. Horse racing excluded The provisions of this chapter shall not apply to horse racing, as that term is defined by § 59.1-365.Acts 2008, c. 860, eff. Oct. 1, 2008.HISTORICAL AND STATUTORY NOTESDerivation:Acts 1991, c. 358; § 3.1-796.131.

§ 3.2-6202. Liability limited; liability actions prohibited A. Except as provided in § 3.2-6203, an equine activity sponsor, an equine professional, or any other person, which shall include a corporation, partnership, or limited liability company, shall not be liable for an injury to or death of a participant resulting from the intrinsic dangers of equine activities and, except as provided in § 3.2-6203, no participant nor any participant's parent, guardian, or representative shall have or make any claim against or recover from any equine activity sponsor, equine professional, or any other person for injury, loss, damage, or death of the participant resulting from any of the intrinsic dangers of equine activities.B. Except as provided in § 3.2-6203, no participant or parent or guardian of a participant who has knowingly executed a waiver of his rights to sue or agrees to assume all risks specifically enumerated under this subsection may maintain an action against or recover from an equine activity sponsor or an equine professional for an injury to or the death of a participant engaged in an equine activity. The waiver shall give notice to the participant of the intrinsic dangers of equine activities. The waiver shall remain valid unless expressly revoked in writing by the participant or parent or guardian of a minor.Acts 2008, c. 860, eff. Oct. 1, 2008.HISTORICAL AND STATUTORY NOTESDerivation:Acts 1991, c. 358; Acts 2003, c. 876; § 3.1-796.132.§ 3.2-6203. Liability of equine activity sponsors, equine professionals No provision of this chapter shall prevent or limit the liability of an equine activity sponsor or equine professional or any other person who:1. Intentionally injures the participant;2. Commits an act or omission that constitutes negligence for the safety of the participant and such act or omission caused the injury, unless such participant, parent or guardian has expressly assumed the risk causing the injury in accordance with subsection B of § 3.2-6202; or3. Knowingly provides faulty equipment or tack and such equipment or tack was faulty to the extent that it did cause the injury or death of the participant.Acts 2008, c. 860, eff. Oct. 1, 2008.

 

RELEASE OF INFORMATION CONTRACT

Participant’s Name: Date of Birth: Age: Parent/Guardian Name:

I hereby authorize Cross Keys Equine Therapy to release and/or exchange protected health information for the above stated Participant for the duration of services received from Cross Keys Equine Therapy with:

Name of Applicable Professional: Organization: Street Address: City & State: Zip Code: Office Phone: Fax Phone: The protected information to be released and/or exchanged include:___ Admission Assessment ___ Substance Abuse Info ___ Mental Status___ Evaluation ___ Discharge Plan ___ Diagnoses___ Treatment Plan(s) ___ Progress Notes ___ Psychological Records___ Court/Agency Documents ___ Communicable Disease ___ Educational Records___ Other (please explain):___________________________________________________________

Purpose of Contract: This form implements the requirements for Participant authorization/consent to use and disclose health information protected by the federal health privacy law (45 C.F.R. parts 160, 164), the federal drug and alcohol confidentiality law (42 C.F.R. part 2), and state confidentiality law governing mental health, development disabilities, and substance abuse services (G.S. 122C).

Redisclosure: Once information is disclosed pursuant to this signed authorization, I understand that the federal health privacy law (45 C.F.R. Part 164) protecting health information may not apply to the recipient of the information and, therefore, may not prohibit the recipient from redisclosing it. Other laws, however, may prohibit redisclosure. When this agency discloses mental health and developmental disabilities information protected by state law (G.S.122C) or substance abuse treatment information protected by federal law (42C.F.R. Part 2), we must inform the recipient of the information that redisclosure is prohibited except as permitted or required by these two laws.

Revocation and Expiration: I understand that, with certain exceptions, I have the right to revoke this authorization at any time. (If I want to revoke this authorization, I must do so in writing.) If not revoked earlier, this authorization expires automatically upon ___________ (Date or event that related to the Participant or the purpose of the use or disclosure) when treatment episode ends or one year from the date it is signed, whichever is earlier. Notice of Voluntariness: I understand that I may refuse to sign this authorization form. If I choose not to sign this form, I understand that Cross Keys Equine Therapy will not deny or refuse treatment because of my refusal to sign.

______________________________________________________ __________________Signature of Participant or Legal Guardian* Date

______________________________________________________*Relationship of Legal Guardian to Participant

STATEMENT OF INFORMED CONSENT AND ACCURACY IN PAPERWORK

Information Received

I acknowledge that I have received, read and fully understand the following information packets:

THRIVE Program Information

Please keep this information packet for your reference.

Application Documents

I acknowledge that I have received, understand, and completely filled out the following documents and that all information is accurate to the best of my knowledge:

ApplicationMedical History and Emergency InformationLiability Release and Assumption of Risk AgreementRelease of Information Contract

All documents referred to in this section are attached to this signature page.

I understand that personal growth and equine interventions are not an exact science and acknowledge that no guarantees have been or can be made to me about the outcomes of these programs/services. Any and all questions I have regarding the contents of this document have been answered to my satisfaction and I would like to proceed with participation in the THRIVE program.

Participant Name:

Printed Signature

Parent/Guardian Name:

Printed Signature

Date:

Photo ReleaseI consent to and authorize the use and reproduction by Cross Keys Equine Therapy of any and all photographs and any other audiovisual materials taken of me/my child/my ward for promotional material, educational activities, exhibitions of or for any other use for the benefit of the organization.

____________________________________________ ________________Client Signature Date

____________________________________________ ________________Signature of Client’s Parent/Guardian Date

Commitment

I commit to being here the following dates:

September 20 September 27 October 4 October 11 October 18 October 25 November 1