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P.O.

Box 4928
Spanaway, WA 98387
253-820-3289
www.changingrein.org

Equine Facilitated Psychotherapy at Changing Rein


Welcome! You are invited to join us to spend some time with our horses while working towards
achieving your mental health goals. During your time with us, you will learn about horse care,
equine behavior and basic horse handling skills. Through planned activities with the horses on
the ground, your therapeutic needs and issues will be directly addressed.
For your comfort and safety, we require that all Changing Rein participants be
properly dressed. Improperly dressed participants will not be allowed to interact with the
horses. That means long pants jeans are best and closed-toed shoes, such as athletic
shoes or boots. Sweats and shorts are not acceptable, neither are sandals or ballet-type
shoes. All shoelaces must be tied up. Short or long-sleeved shirts are required. No sleeveless
shirts or tank tops. Tops must cover the shoulder and midriff. The reason for these clothing
restrictions is that you will be in a barn environment where loose clothing can get caught on
equipment, sharp corners or be a temptation to a horse to grab with its teeth. Exposed skin
can be easily cut on equipment or scraped against tack, equipment, stall doors, fences or
gates. Also, horses occasionally brush up against people and we need protection against our
skin if they do this. Closed-toed shoes protect our feet in case a horse accidentally steps on
our toes.
We will be outside for most of our guided interactions. It is important to wear sun block and
have a bottle of water each time you come to the property. You might also want to wear
sunglasses, a hat and a pair of leather or garden gloves to protect your hands. It is strongly
recommended that you wear knee-length socks to prevent the sand and footing thats in the
arena and stalls from working its way into your shoes.
We want you to come to the farm and be safe and comfortable! Following the guidelines listed
above will help make that happen.
We and the horses look forward to meeting you soon!
Ruth and Sandra
Co-Facilitators Equine Assisted Psychotherapy
Changing Rein EAAT

2012 Changing Rein Equine Assisted Activities and Therapies. | Hands on Horses Application |
Warning: Under Washington Law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in
equine activities resulting exclusively from the inherent risks of equine activities.

P.O. Box 4928


Spanaway, WA 98387
253-820-3289
www.changingrein.org

Participant Application
Date of Application: _______ / _______ / _______
Name (First/Middle/Last):
_______________________________________________________________________________
DOB: ______ / ______ / ______

Age: _________

Gender:

M / F

Address:
____________________________________________________________________________________________
City: __________________________________________________ State: _________________ Zip Code:
______________
Phone: (H)____________________________ (C)____________________________
E-mail:
______________________________________________________________________________________________
PARENTAL CONSENT FOR PARTICIPANTS UNDER THE AGE OF 18:
Parents/Guardians
(First/Middle/Last):___________________________________________________________________
Address: ___________________________________________________________________________________________
City: ________________________________________________ State: ___________________ Zip Code:
______________
Phone: (H)__________________________ (C)____________________________
(W)______________________________
E-mail: _____________________________________________________________________________________________
EMERGENCY CONTACT INFORMATION
Name: ____________________________________ Phone:
____________________________________________________
Name: ____________________________________ Phone:
____________________________________________________
Have you been around horses in the past? YES

NO

If so, tell us about your experience:

Do you have any concerns about working with or around horses?


2012 Changing Rein Equine Assisted Activities and Therapies. | Hands on Horses Application |
Warning: Under Washington Law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in
equine activities resulting exclusively from the inherent risks of equine activities.

P.O. Box 4928


Spanaway, WA 98387
253-820-3289
www.changingrein.org

2012 Changing Rein Equine Assisted Activities and Therapies. | Hands on Horses Application |
Warning: Under Washington Law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in
equine activities resulting exclusively from the inherent risks of equine activities.

P.O. Box 4928


Spanaway, WA 98387
253-820-3289
www.changingrein.org

Health/Fitness:
Height ________ Weight ________
Can you easily lift 30 to 50 pounds over your head?
Do you have allergies to horses, hay or pollens?

YES / NO
YES / NO

Please list all relevant diagnoses and current medications:


___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
SAFETY COMMITMENT
I agree to be responsible for keeping myself and others safe by following all the rules and guidelines
as outlined and explained by the program staff. Safety procedures will be explained and reviewed
each day and I understand it is my responsibility to follow them to the best of my ability.
PARTICIPANT SIGNATURE: _____________________________________________________ DATE
_____/_____/_____

Photo Release
Photo Release / Non Consent
For valuable consideration and which is hereby acknowledged, the undersigned herby grants
permission to Changing Rein, LLC to take or have taken still and moving photographs and films,
including television footage, of the following individual:
Name_______________________________________________________ Date of Birth_____/______/__________
(please print)
The undersigned hereby gives consent and authorizes Changing Rein, LLC in its work to use and
reproduce the photographs, films, and footage to circulate and publicize the same by all means,
including and without limit too, the generality of the newspapers, television, media, brochures,
pamphlets, instructional materials, books and clinical materials.
With regard to the foregoing material, no inducement or promises have been made to us/me to
secure our/my signature(s) to this release other than the intention of Changing Rein, LLC to use or
have used such photographs, films, and footage for the primary purpose of promoting and aiding
Changing Rein, LLC and its work.
______ I give my consent for the Photo Release.
______ I do not give my consent for the Photo Release.
Participant Signature ______________________________________________ DATE _____/_____/_____
Parents Signature (if under 18)
_____________________________________________DATE_____/_____/_____
2012 Changing Rein Equine Assisted Activities and Therapies. | Hands on Horses Application |
Warning: Under Washington Law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in
equine activities resulting exclusively from the inherent risks of equine activities.

P.O. Box 4928


Spanaway, WA 98387
253-820-3289
www.changingrein.org

2012 Changing Rein Equine Assisted Activities and Therapies. | Hands on Horses Application |
Warning: Under Washington Law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in
equine activities resulting exclusively from the inherent risks of equine activities.

P.O. Box 4928


Spanaway, WA 98387
253-820-3289
www.changingrein.org

RELEASE OF LIABILITY AND ASSUMPTION OF RISK


FOR GOOD AND VALUABLE CONSIDERATION, the receipt of which is hereby acknowledged,
the undersigned agrees as follows:
I.

ACKNOWLEDGEMENTS
a. The undersigned acknowledges that all equestrian activities and events are inherently
dangerous events and that participation as a competitor, student, observer, volunteer or
paid laborer in any of these events exposes the participant to substantial and serious
hazards and risks of property damage, personal injury and/or death.
b. The undersigned acknowledges that grooming, leading, saddling, mounting, observing,
feeding, and any other activity involving horses exposes the actor to substantial and
serious hazards and risks of property damage, personal injury, and/or death.
c. The undersigned further acknowledges that riding horses in the company of other riders
and horses, whether for pleasure or in a structured event, exposes such rider to
substantial and serious hazards and risks of property damage, personal injury, and/or
death.

II.

RELEASE OF LIABILITY
a. The undersigned agrees to release David and Sandra Boe, Changing Rein LLC, its
members, agents and employees from any and all claims, demands and liabilities
resulting from personal injury, property damage, and/or death arising from the
undersigneds participation in any equestrian event, equine activity, or personal equine
endeavor held in any equine facility that may be designated, currently designated as
David and Sandra Boe, Changing Rein, LLC 6204 288 th St E Graham WA 98338. This
release includes claims, demands and liabilities that are known or unknown, foreseen or
unforeseen, future or contingent, and includes all claims, demands, and liabilities arising
out of negligence by Changing Rein LLC, its members, agents, and employees.
b. The undersigned further agrees to release David and Sandra Boe, Changing Rein LLC, its
members, agents, and employees from any and all claims, demands, and liabilities by
the undersigned for indemnities and contributions arising from property damage,
personal injury, and/or death to a third party.

III.

ASSUMPTION OF RISK
a. The undersigned, having acknowledged the inherent danger associated with
participation in equestrian riding events and equine activities, whether as a competitor,
student, observer, volunteer or paid laborer, hereby voluntarily, knowingly, and expressly
assumes the inherent risks and hazards described herein.
b. The undersigned, having acknowledged the inherent danger associated with riding a
horse in the company of other riders and horses, hereby voluntarily, knowingly, and
expressly assumes the risks and hazards described herein.
c. The undersigned, having acknowledged the inherent danger associated with grooming,
leading, saddling, mounting, observing, feeding and any other activity involving horses,
hereby voluntarily, knowingly, and expressly assumes the risks and hazards described

2012 Changing Rein Equine Assisted Activities and Therapies. | Hands on Horses Application |
Warning: Under Washington Law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in
equine activities resulting exclusively from the inherent risks of equine activities.

P.O. Box 4928


Spanaway, WA 98387
253-820-3289
www.changingrein.org

herein.

2012 Changing Rein Equine Assisted Activities and Therapies. | Hands on Horses Application |
Warning: Under Washington Law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in
equine activities resulting exclusively from the inherent risks of equine activities.

P.O. Box 4928


Spanaway, WA 98387
253-820-3289
www.changingrein.org

IV.

SEVERABILITY
a. In the event that any provision of this release and assumption of risk is found to be
invalid, unenforceable, or voidable, the remaining provisions shall remain in full force and
effect as if this agreement had been executed without the invalid provision.

V.

INDEMNIFICATION
a. The undersigned agrees to indemnify and save and hold David and Sandra Boe,
Changing Rein LLC its members, agents, and employees, harmless from any and all
claims, demands, and liabilities for any and all property damage, personal injury, and/or
death asserted by a third party that was occasioned by the undersigneds participation in
any equestrian event on the designated equine facility.

VI.

GOVERNING LAW
a. The undersigned agrees that this agreement shall be subject to the laws of the State of
Washington and that any dispute regarding this agreement shall be subject to the
jurisdiction and venue of the State of Washington Superior Court in and for Pierce
County.

VII.

HEIRS, ASSIGNS, SUCCESSORS


a. The undersigned agrees that this agreement shall be binding upon the heirs, assigns and
successors of the undersigned. If the undersigned is a minor child, the parent or
guardian of the minor child hereby agrees to the provisions of this agreement in total
and is thereby bound by the same, as evidenced by his or her signature below.

DATED THIS ___________ day of _____________________, 20__.

___________________________

____________________________________________

___________________________

_____________________________________________

Print Name

City, State, Zip

Signature

Address

PARENTAL/GUARDIAN STATEMENT FOR PARTICIPANTS UNDER THE AGE OF 18:


I hereby certify that I am the parent or legal guardian of the child whose signature appears above. I
have explained the assumptions of the risk contained herein to the child and believe that the child
reasonably understands the risks involved and is willing to assume these risks. I believe that the
child understands the release of liability in favor of David and Sandra Boe, Changing Rein, LLC and
that the child has freely tendered such release. As parent or legal guardian of the child, I hereby
ratify the provisions of the foregoing agreement and agree to be bound by its provisions.
DATED THIS _____________ day of ____________________________, 20_____.

___________________________
Signature of Parent or Guardian

____________________________________________
Address

___________________________

_____________________________________________

Print Name

City, State, Zip

2012 Changing Rein Equine Assisted Activities and Therapies. | Hands on Horses Application |
Warning: Under Washington Law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in
equine activities resulting exclusively from the inherent risks of equine activities.

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