EmailMeForm
Equine Therapy Registration - Waitlist
Saturday, April 20th, 2024, from 9am - 12pm
13133 Brown Rd. Baker, LA 70714
Child Attending
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First
Last
Age of Child
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Please select
6
7
8
9
10
11
12
13
14
Additional Child Attending
First
Last
Age of child
Please select
6
7
8
9
10
11
12
List any additional children attending and their ages
Does the child have any known allergies?
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Yes
No
Please specify
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Attending Adult Name
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First
Last
Attending Adult Phone Number
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Attending Adult Email
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How many adults will be attending the event?
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Address
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Street Address
City
State / Province / Region
Postal / Zip Code
Emergency Contact Name
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First
Last
Emergency Contact Phone Number
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Reason for attending Equine Therapy (list your child's recent grief related experience)
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How did you hear about this event?
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THBR Staff
THBR Website
Social Media
Marketing Event
Word of Mouth
Other
VIDEO/PHOTOGRAPH RELEASE
I hereby grant The Hospice of Baton Rouge the irrevocable right and permission to use photographs and/or video recordings of me at events such as Camp Conquer, Family Day, or other events and other websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me.
I understand and agree that such photographs and/or video recordings of me may be placed on the Internet. I also understand and agree that I may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of me. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of The Hospice of Baton Rouge.
I hereby release, acquit and forever discharge the State of Louisiana, The Hospice of Baton Rouge, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.
I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below. This release is binding on me and my heirs, assigns and personal representatives.
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Yes
No
Signature
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Clear
