Reins From Above Therapeutic Riding Center, Inc.
841 Wiggins  Road
Angier, NC 27501
Phone: 919-631-9294
Website: www.reinsfromabove.org

** Please note that horseback riding is contraindicated for some conditions/individuals, and Reins From Above Therapeutic Riding Center, Inc. reserves the right to consider each application and deny services to individuals based upon concerns for the applicant’s safety and/or the safety of the horses, volunteers, staff, or property owners, or for other reasons. Please refer to Reins From Above Therapeutic Riding Center, Inc.’s Policies and Barn Rules for guidelines. ** 
PARTICIPANT REGISTRATION AND RELEASE FORM 
Date: _____________________________
Client Name: __________________________________________________ Date of Birth: _____________ Age:__________ 
Street/P.O. Box: ________________________________________ City___________________ State______ Zip_________ 
Home Phone: _______________________Work Phone______________________ Cell Phone________________________ 
Email Address: ___________________________________________ Social Security Number: _______________________
Parents or Guardian(s):________________________________________________________________________________ Address_______________________________________________________________Phone:________________________ 
Adult Caretaker, if any: ___________________________________________________Phone________________________ 
School or institution presently attending: ___________________________________________________________________
In case of emergency contact: __________________________________________________Phone:___________________ 
Or contact: _________________________________________________ Phone:___________________________________ 
PHOTO/VIDEO/MEDIA RELEASE 
I consent to and authorize the use and reproduction by Reins From Above Therapeutic Riding Center, Inc. of any and all photographs and any other audiovisual, videotape, or digital media materials taken of me/my child/my ward for promotional printed material, internet website, educational activities, exhibitions or for any other use for the benefit of Reins From Above Therapeutic Riding Center, Inc. or the North American Riding for the Handicapped Association (NARHA). 
Date:_________________ Signature of Participant:_________________________________________________ Print Name of Participant:______________________________________________________________________ 
Parents or guardians with legal custody must sign IF participant is under eighteen (18) years of age or otherwise under a legal disability. 
Date____________________ Signature of Parent/Guardian__________________________________________ 
Print Name_________________________________________________________________________________ Date____________________ Signature of Parent/Guardian__________________________________________ 
Print Name_________________________________________________________________________________