2022 Animal Assisted Learning Program Registration & Release Form

AAL Registration and Release
First Last
Address
Address
City
State/Province
Zip/Postal

Health History Information

Able to navigate uneven surfaces?

Please indicate if the client has a history of the following:

Seizures
Allergies
Bees
Animals
Dust
Asthma

Liability Release

Parent or Guardian

Photo Release

Yes or No

hereby grant irrevocable and unlimited consent to the use and reproduction by Main Stay Therapeutic Farm, its assigns, licensees and legal representatives, of any and all photographs and any other audio/visual materials taken of me, my child or my ward, in all forms and media (including but not limited to printed media, digital media, web sites, video and audio productions). The materials may be reproduced in all forms including composite, altered or derivative works, for promotional material, educational activities, and exhibitions or for any other lawful use for the benefit of the program.

I hereby waive the right to inspect and approve the finished version(s) including any copy that may accompany the materials. I hereby release Main Stay and its employees, volunteers, assigns, licensees and legal representatives from all claims and liability relating to said materials. I sign this release as a person with, or the parent or guardian of a person with special needs, understanding that use of these materials will make them available to the general public. I am the parent or guardian of the minor child, or dependent adult named above and have the legal authority to execute the above release. I approve the foregoing and waive any rights in the premises.

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