EmailMe Form - Equine Therapy Registration

Child Attending *

First Last

Age of Child *

Additional Child Attending

First Last

Age of child

List any additional children attending and their ages

Does the child have any known allergies? *

Yes

No

Please specify

Emergency Contact Name *

First Last

Emergency Contact Phone Number *

### - ### - ####

Email *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Reason for attending Equine Therapy (list your child's recent grief related experience) *

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 Equine Therapy, 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.

Clear

Signature