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Y0J$$$l          J    $         $ 2:  Reins for Life Therapeutic Riding at Poplar Ridge Stables 2685 Armstrong Rd ( Wooster, Oh 44691 ( Phones: 330-464-3380 or 330-988-3386 E-mail: narhainstructor@yahoo.com ( www.ccho.org Rider Registration and Release Form Riders Name (Please print): ___________________________________________________________________ Address: __________________________________________________________________________________ City___________________________________________________________________State_____Zip_________ County____________________ Birth Date (Riders) ________________ Age: ______ Home Phone___________________________ Cell Phone ______________________________ Work Phone____________________________ E-mail Address ________________________ Parent/Guardian Name (Please print): ___________________________________________________________ Address: __________________________________________________________________________________ City___________________________________________________________________State_____Zip_________ County____________________ Home Phone___________________________ Cell Phone ______________________________ Work Phone____________________________ E-mail Address ________________________ School/Institution currently attending: ___________________________________________________________ In case of Emergency: Name: ________________________________________ Phone: _____________________________________ Name: ________________________________________ Phone: _____________________________________ Liability Release ______________________________would like to participate in the Christian Childrens Home of Ohio Reins for Life program. I acknowledge the risks and potential for risks of horseback riding. I am aware that horses can kick, bite, throw riders or otherwise cause injury to riders or other persons in the vicinity. I am aware that horses can act in accordance with their own will. I am aware that horseback riding or working in close proximity with horses is a hazardous activity, and I and/or my child or ward are voluntarily participating in this activity with knowledge of the danger involved and accept any and all risks of injury. I hereby, intending to be legally bound, for myself, and, if executing this release on behalf of my child or ward, on behalf of such child or ward, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against Christian Childrens Home of Ohio Reins for Life program, its board of directors, instructors, therapist, aides, volunteers and or employees for any and all injuries and/or losses I/my child/my ward may sustain while participating in Christian Childrens Home of Ohio Reins for Life program. If executing this release on behalf of my child or ward, I further give permission for my child or ward to participate in tasks related to the maintenance of the programs facilities or grounds, including such grounds as may comprise part of the property owned by Christian Childrens Home of Ohio, and release all parties named herein from any claims or losses associated with such participation, as set forth above. Date: ______________ Signature: _________________________________________________ Rider (if adult) or Parent/Guardian (if under 18 yrs) Photo/Name Release I consent to and authorize the use and reproduction by Christian Childrens Home of Ohio Reins for Life program of any and all photographs and any other audio-visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program. I also hereby consent to and authorize Christian Childrens Home of Ohio Reins for Life program to identify me/my son/my daughter/my ward by full name and use my/my sons/my daughters/my wards full name for promotional printed material, educational activities or for any other use for the benefit of the program. Date: ______________ Signature: _________________________________________________ Rider (if adult) or Parent/Guardian (if under 18 yrs) Riders Confidentiality and Non-Disclosure Agreement As a Rider of Christian Childrens Home of Ohio Reins for Life program you may obtain information about the medical condition, diagnosis or treatment of program participants. This information is highly confidential, and Christian Childrens Home of Ohio Reins for Life program makes every effort to protect the confidentiality of program participant medical information. As a Rider, we ask you to respect this confidentiality and not share such information with any person or organization outside Christian Childrens Home of Ohio Reins for Life program without the expressed consent of the persons involved. Agreement I do affirm that I will not divulge any medically related information regarding any Christian Childrens Home of Ohio Reins for Life program participant to any unauthorized person for any reason. Neither will I directly nor indirectly use, or allow the use of, Christian Childrens Home of Ohio Reins for Life program information for any purpose other than that directly associated with Christian Childrens Home of Ohio Reins for Life program. I understand that all program participant information is strictly confidential. __________________________________ Rider or Guardian (if under 18) signature __________________________________ Rider or Guardian printed name ___________________ Date     Reins for Life at Poplar Ridge Stables ( 2685 Armstrong Rd., Wooster, Oh 44691 ( Tel.330-464-3380 & 330-988-3386 (  HYPERLINK "mailto:narhainstructor@yahoo.com" narhainstructor@yahoo.com ;<NObcij˱xfWfJhu"hvF~OJQJ^Jh`5CJOJQJ^JaJ#hu"hS&z5CJOJQJ^JaJhS&zCJOJQJhvF~5CJ OJQJhEW&5OJQJ jhQh 5OJQJhQh 5OJQJ3hrh 5B*CJ,OJQJaJ,mHnHph1u(hrh 5B*CJ,OJQJaJ,ph1h mHnHu,jhrhrOJQJU^JmHnHu<E F   R S Y Z  gd`gd24gdvF~$a$gd $a$gd ( D   E Q R  < X 1 2 $c,?鳢r hUhn}CJOJQJ^JaJ hUh_3CJOJQJ^JaJh_3CJOJQJ^JaJ hUh24CJOJQJ^JaJ#hUh245CJOJQJ^JaJhu"h`OJQJ^Jh`h`OJQJ^Jh`OJQJ^Jhu"h24OJQJ^Jh OJQJ^J,  3 4 = > T $%hij*+,?@  !gd24gd24gd`?w/9pqo9CYZ78(Pӣtfh<.CJOJQJ^JaJ hUh`CJOJQJ^JaJ hu"h24CJOJQJ^JaJhu"h24OJQJ^J hUh(CJOJQJ^JaJh(CJOJQJ^JaJ hUhu"CJOJQJ^JaJhU CJOJQJ^JaJh_3CJOJQJ^JaJ hUh24CJOJQJ^JaJ(opq78BFYZ}    gd24gd24   9;<>PRceflopstƹtc h:h0JCJOJQJ^JhPB@CJOJQJ^J" jhah CJOJQJ^Jhah CJOJQJ^Jh CJOJQJ^Jh.Tjh.TUhu"h0OJQJ^Jhu"h24OJQJ^Jh(CJOJQJ^JaJ hUh24CJOJQJ^JaJh^CJOJQJ^JaJ$$a$gdvF~$ !]a$gd ˼hu"h0OJQJ^Jh.ThvF~hahCJOJQJ^Jh @CJOJQJ^J'jh.T0J@CJOJQJU^J$h:h0J@CJOJQJ^J21h:p`/ =!"#$`% Ddp+  A?4foxtrot linePicture 4Description: foxtrot line"b|dD}PDn|dD}PPNG  IHDR%[OPLTEU$$U$$IIUIImmUmmUUU۪U$$U$$$$$$U$$$$$I$IU$I$I$m$mU$m$m$$U$$$$U$$$$U$۪$$$U$$IIUIII$I$UI$I$IIIIUIIIIImImUImImIIUIIIIUIIIIUI۪IIIUIImmUmmm$m$Um$m$mImIUmImImmmmUmmmmmmUmmmmUmmmmUm۪mmmUmmU$$U$$IIUIImmUmmUUU۪UU$$U$$IIUIImmUmmUUU۪UU$$U$$IIUIImmUmmےےUےے۶۶U۶۶U۪UU$$U$$IIUIImmUmmUUU۪Un.bKGDH cmPPJCmp0712HsIDAThCZMj#YT"2H hQ ^Aj0 =ttU vKDLZb$Vf//"^j,PuuSwuם3mzw5~u8o4uë?<7X`,!d5~U`91N~dO$E[9qux{1kJvq~# 0Ş`gp3=fzoϝ5 J0X+"#SS\[gFB ~utUC=袞Xx;rrW+WD }:}XU3$FuǢyZa]]Ȧ=ҹ(xZx|8K:S6vq,~qqyw/FkuUuQ>C25Cëx!z=Hѓç/8G*I]}Os ȬİObTGlY׊Mښow>kU1k MߣyGě \D; RDWQ7;Ծg|\0 IZ0(oBfӀGAD  _z&4Q/Nm]-"`jMø^# ¡\)IN72\H+qMK <%M*!)Qc٫e 2AnUP!Fw=t-]2/OAa ɛ `?yw,ôPu40w2_ӊ҇u_9<ƞ6C_-W d3ӄ#6+ˡzB~3t787o7oDNBD&cDԁD}6_U ȣkjp}$jF [9:Xdȅ2M!y94ps,@UxDhR>8"WaET32VkV k=+8)~/[/>= "1#"$hBr6quP6C }U9XiDO#$F|L[3Lq{ 8JӈȽ[?  בBI ֝S1K"CVxM#^k);o6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH 8`8 vF~Normal_HmH sH tH B@B 24 Heading 1$@&5CJ \aJDA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List 4@4 vF~0Header !4 @4 vF~Footer !6U`6 vF~ Hyperlink >*B*ph.!.  0 Header CharH@2H _30 Balloon TextCJOJQJ^JaJNoAN _30Balloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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