MoonRise Therapeutics Assumption of Risk Form/Photo Release/Mailing List/ Emergency Medical Treatment Authorization/Participant Information/ Combined Online Form

MoonRise Therapeutics Assumption of Risk Form

MoonRise Therapeutics, Inc. is committed to protecting safety and well-being of all involved.

Obligations of All Visitors/Users:

To protect my safety and the safety of all I come in contact with at MoonRise Therapeutics, I agree to follow all safety rules set out by MoonRise Therapeutics. I also agree to stay home and reschedule if I have a fever and/or a contagious illness including COVID-19 or Influenza.

Assumption of Risk:

1.Visitors understand that use of the property, horses and equipment has inherent risk to themselves and their property. By accessing the property, horses and equipment, visitors agree to assume all risks of injury and damages and to hold the Owners harmless for any and all injury to their person or property.

2. Visitors agree, at their cost, to defend, indemnify and hold harmless, the Owners, MRT employees, volunteers and any agents of the work of MRT, from and against any and all claims, suits, liens, judgments, damages, losses and expenses including reasonable attorney fees and legal expenses and costs arising in whole or in part and in any manner from damages to persons or property which result from access to the property, horses and equipment

Under Vermont Law, an equine activity sponsor is not liable for an injury to, or the death of, a participant in equine activities resulting from the inherent risks of equine activities that are obvious and necessary, pursuant to 12 V.S.A 1039.

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Assumption of Risk Form

Thank you for filling out the MoonRise Therapeutics Assumption of Risk Form. Your form has been sent to our team.

Participant’s Name

MoonRise Program You are Attending / Group and Date(s) of Program

Date or Birth

Caregiver’s Name (if Participant is under 18)

If attending a family program you may add additional names: (minors-under 18)

Phone

I authorize the use of this phone number to send me text messages for scheduling updates.

Address

Photo Permission

Choose several options

I hereby DO authorize MoonRise Therapeutics, Inc. (MRT) and MoonRise Farm (MRF) and give my full consent to copyright and/or publish any and all photographs, video and/or film in which I appear while participating in equine programs, so long as the use is solely for training staff and personnel, and for advertising, but not for sale or commercial reuse. I do not give photo permission.

Mailing List

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Join our mailing list and stay up to date on MoonRise programs and events. ( you can unsubscribe at any time).

MoonRise Therapeutics Emergency Medical Treatment Authorization

Choose several options

Emergency Medical Treatment Consent Plan I hereby DO authorize MoonRise Therapeutics, Inc. (MRT) and MoonRise Farm (MRF) in the event emergency medical aid/treatment is required due to illness or injury while being on the property at MoonRise Farm I authorize MoonRise Therapeutics staff or volunteers to secure and retain medical treatment and transportation if needed. This authorization includes x-rays, surgery, hospitalization, medication and any treatment procedure deemed “ life saving” by the physician.

Emergency Contact Phone Number

Primary Physician Phone Number

Health Insurance Company and Policy Number

Preferred Medical Facility

Health History Please describe any information that would be necessary for doctors to know should you need emergency services

Do you experience any mobility issues? If so, how can we assist you?

Do you have a disability? If so, how can we accommodate your needs?

Medications

Medication Side Effects?

Allergies

Seizures

Date of Last Tetanus Shot

Participant Information Form

Thank you for completing the MRT participant information form. Your responses will help us in gathering information to provide you with the best assistance and ensure your safety.

What are some of your special interests/strengths?

What would you like to learn?

Have you been diagnosed with any emotional health conditions?
If yes, please specify:

Do you require any accommodations for participating with MRT?
If yes, please specify how we can accommodate your needs.

Other Information that would be helpful to know :

Choose several options

I/WE HAVE READ THE ABOVE, MOONRISE THERAPEUTICS, ASSUMPTION OF RISK POLICY and EMERGENCY MEDICAL TREATMENT AUTHORIZATION and UNDERSTAND THAT I/WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, HAVE NOT CHANGED IT ORALLY, AND SIGN IT VOLUNTARILY. I agree to sign the agreement electronically by typing in my name below.

Type Your Name as Your Electronic Signature