Full name of the participant:

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Full name of the person filling out this form:

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Event/program attended:

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Participant date of birth:

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Diagnosis (if applicable):

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PHOTO RELEASE: The undersigned hereby grant(s) Inspired Acres to take or have taken, still and moving photographs and films including television pictures of the undersigned and consents and authorizes Inspired Acres, its advertising agents, news media, and any other persons interested in Inspire and its work, to the use and reproduction of the photographs, films and pictures without limit, the generality of the foregoing newspapers, television media, social media, Inspire website, brochures, pamphlets, instructional materials, books and clinical material.

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NAME RELEASE: The undersigned hereby grant(s) Inspired Acres to use the undersigned's full name and consents and authorizes Inspired Acres, its advertising agents, news media, and any other persons interested in Inspired Acres, and or its work, to the use of her/his name with photographs, films and pictures without limit, the generality of the foregoing newspapers, television media, social media, Inspire website, brochures, pamphlets, instructional materials, books and clinical material..

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With regard to the foregoing material, no inducements or promises have been made to us/me to secure our/my signature(s) to this release other than the intention on Inspired Acres to use or be in use or be used the aforementioned name and such photographs, films and pictures for the primary purpose of promotion and aiding its program and or its work.

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Note: Signature of Parent/Guardian is REQUIRED if Constituent is UNDER THE AGE OF 18 or is AN ADULT AND UNDER GUARDIANSHIP.

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LIABILITY RELEASE: Know all men by these present: That the undersigned who is known to Inspired Acres as a visitor, volunteer, participant, employee or guest, (hereinafter referred to as “Constituent”), for and in consideration of participation in any Inspired Acres Programs and presence on any Inspired Acres property and for other good and valuable consideration in hand received by Constituent, the receipt and adequacy of which are hereby acknowledged, does hereby RELEASE AND HOLD HARMLESS, Inspired Acres, a Florida nonprofit corporation, 2001 KJ Trust Agreement Utd. 2-11-11, Apharo to the Son and it’s successors and /or assigns, agents, principals, representatives and employees, (hereinafter collectively referred to as “Inspired Acres”) of and from all manner of action(s), cause(s) of action, suits, controversies, agreements, promises, damages, judgments, executions, claims and demands whatsoever, in law or in equity, which Constituent has or may have in the future from the signing of this release until the end of such Constituent’s participation in an Inspired Acres program or presence on Inspired Acres property, and any claim past, present or future which any personal representative, successor, heir or assignee of said party hereafter can, shall or may have against Inspire for, upon or by reason of any matter, cause or thing whatsoever, from the time of Constituent participation in any Inspired Acres program or being present on any Inspire property until such time as Constituent is not participating in any Inspire program or from a date forward that such Constituent is not present on any Inspired Acres property, such release and hold harmless of Inspired Acres specifically includes, but not by way of limitation, the following: 1) All equine activities at the property leased by Inspire located at 1743 Doncaster Rd, Clearwater, Pinellas County, Florida, including, handling, care, grooming, leading, riding, driving of horses and such activities as defined in Section 773.01, Florida Statues, as amended from time to time; and all activities related to being in the presence of horses or on Inspire property; 2) Any and all rights or claims arising from, relating to, or in any way connected with the death or injury of any person participating in any equine activity sponsored by Inspired Acres or death or injury of person occurring on Inspire property or claim for damage to any Constituent’s personal property brought upon any Inspired Acres property by Constituent. 3) Constituent grants Inspired Acres the right and authority to perform a background check on Constituent in advance of Constituent’s participation in any Inspired Acres activity or presence on Inspired Acres property and Inspired Acres may make future checks on background from time to time during the Constituent’s involvement in any Inspired Acres program or presence on Inspired Acres property. Constituent releases Inspired Acres from any claim, cause of action or damages based upon Inspires authorized background check(s). 4) Any and all rights or claims arising from, relating to or in any way connected with the death or injury of a Constituent who takes transport in any Inspired Acres agent vehicle as part of a sponsored Inspired Acres program occurring outside of the Inspired Acres property. WARNING Under Chapter 773, Florida Statutes, an equine activity or sponsor or equine professional is not liable for any injury to, or the death of, a participant in equine activities resulting from the inherent risks of equine activities. This Release further incorporates the immunity to volunteers of not-for- profit organizations who are acting within the scope of their responsibilities and who do not cause harm willfully or with wanton disregard for safety. Note: Signature of Parent/Guardian is REQUIRED if Constituent is UNDER THE AGE OF 18 or is AN ADULT AND UNDER GUARDIANSHIP

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If you require any disability-specific adaptions, please list them below:

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I understand that ALL participants under 18 or with a legal guardian must have a caregiver/guardian ON SITE for the duration of each program.

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