Equine-Assisted /Animal-Assisted Therapy Liability Release Form

Participant Name Name

Please Read Carefully Before Signing

Please check ALL of the items below:

I understand that under the Equine Activity Liability Act, each participant who engages in an equine (horse) activity expressly assumes the risks of engaging in and legal responsibility for injury, loss, or damage to person or property resulting from the risk of equine activities.
I understand that Animal-Assisted Therapy, includes equines, donkeys, dogs, cats, ducks, pigs and lambs and each participant who engages in an animal activity expressly assumes the risks of engaging in and legal responsibility for injury, loss, or damage to person or property resulting from the risk of animal activities.
This release shall give notice to the participant, parent, or guardian the risks of engaging in Equine Assisted activities, including (I) the propensity of equines to behave in dangerous ways that may result in injury to the participant, (II) the inability to predict an equine’s reaction to sounds, movements, objects, persons, or animals, and (III) the hazards of surface or subsurface conditions. A release shall remain valid until expressly revoked in writing by a participant, or, if a minor, the parent or guardian.
This release shall give notice to the participant, parent, or guardian the risks of engaging in Animal-Assisted activities, including (I) the propensity of animals to behave in dangerous ways that may result in injury to the participant, (II) the inability to predict an animal’s reaction to sounds, movements, objects, persons, or animals, and (III) the hazards of surface or subsurface conditions. A release shall remain valid until expressly revoked in writing by a participant, or, if a minor, the parent or guardian.
I consider these risks to be offset by the benefits that may be received by visiting/working with the animals at ERC Stables, Marengo, IL and Fields For Growth, Marengo, IL. These benefits may include, but are not limited to higher self-esteem, confidence, personal awareness, character development, leadership skills, problem solving skills, social skills, increasing therapeutic goals, and developing respect for self and others.
I understand that participants must provide Dr. Sandra Kakacek, Licensed Clinical Professional Counselor and/or Ms. Kaitlyn Twardzik, Licensed Professional Counselor, medical information regarding any prescription drugs being used or any health or physical condition that may need to be considered at least 24 hours prior to sessions. For safety reasons a participant may not actively participate in sessions if they are pregnant, or under the influence of illegal drugs or alcohol.
Participants must wear long pants, closed toe and heel, hard soled shoes; remove any dangling jewelry, or any other loose items that may put the participant at risk. Winter: please wear a coat, hat and gloves. Summer: please wear sunscreen and insect repellant as needed for outside activities and bring a bottle of water.
I understand that 24-hour notice of cancellation is required. I also understand that if I am late, the session must end as scheduled. I must contact Dr. Sandra Kakacek directly by telephone to notify of cancellation, lateness or any changes of schedule at 630.675.3944.
I hereby release Dr. Sandra Kakacek and therapists, counselors, counselors-in-training, facility, and landowners, employees, independent contractors, and volunteers, who work with her from any responsibility or liability for injury, loss, damage to person or property, including malpractice, resulting from equine and other animals activities and/or visiting the facility.

I have read and understand the provided information and agree with the terms in their entirety.

Participant Name *

Participant Signature *

Clear Signature

Parent or Guardian Name *

Parent or Guardian Signature *

Clear Signature

Parent or Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Parent or Guardian Phone

Witness Name *

Witness Signature *

Clear Signature

Today's Date *