461 Cann Road ♦ West Chester, PA 19382 ♦ Phone 610.692.6362 ♦ Fax 610.692.0917 ♦ www.QuestTherapeutic.

com

January 2018 INFORMATION & LIABILITY

Name: _____________________________________________ Date of Birth_______________________________

Address:________________________________ City: _______________________ State: _____ Zip:___________

Tel: (H) _________________ (Cell / Text) _________________ Email:____________________________________

(Please circle one of the above for best method of contacting you in case of weather or scheduling changes)

If under 18: Father, Mother, Guardian Name (please circle)_____________________________________________

♦ IN CASE OF EMERGENCY, PLEASE CONTACT ♦

Parent(s)/Spouse/Guardian/Caregiver (please circle) ________________________Contact Phone:_____________
♦ LIABILITY RELEASE ♦
I understand________________________________(name) that horses are unpredictable by nature and I voluntarily
assume the risks and dangers involved. I hereby, intending to be legally bound, for myself, my heirs, executors or
administrators, waive and release all claims for damages I may have against Quest Therapeutic Services, Inc., its
Owners, Therapists, Instructors, Volunteers, Aids, and/or Employees for any and all injuries and/or losses.
♦ MEDICAL RELEASE ♦
The above person hereby (check one) “Consents____”, “Does not consent____” to any medical, dental, or surgical
treatment or procedure of an emergency nature that is reasonably necessary to save the life of the person named
above or to restore the person to health. I understand that should medical emergency treatment be required, the
current insurance information listed here will be provided to the attending clinic or hospital to cover future payment
of incurred bills.
♦ INSURANCE ♦
The above person carries medical insurance: Yes__ No__, Insurance Co.__________________ Policy #_________
♦ PHOTO RELEASE ♦
The above person hereby (check one) “Authorizes ____”, “Does not authorize ____” the use and reproduction by
Quest Therapeutic Services, Inc. of any and all photographs taken for marketing, social media or printed materials.
♦ POLICY OF CONFIDENTIALITY ♦
All information about participants at Quest including but not limited to, personal, medical, and financial documents
are confidential among all participants, volunteers, and staff. Confidentiality is a basic important value here at
Quest, and is also applicable under the HIPPA guidelines which protects the privacy of clients here at Quest.
♦ ACCEPTANCE OF ABOVE POLICIES ♦
I have read, understand and will respect Quest’s policies as they pertain to ♦ Release of Liability, ♦ Photo Release,
and ♦ Policy of Confidentiality.

Signed:_______________________________________________________________ Date:_________________

Parent’s Signature (if under 18):___________________________________________ Date:_________________

For office use only: _____ Attended Orientation _____ Completed Leader Training
_____ Entered in Volunteer Database ______________ Start Date
Clearances received: ____ Childline ____ PA State Police ____ FBI Fingerprint ____ Waiver