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EAAL Registration and Release Form

Equine and Animal Assisted Learning Program

Health History Information

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


I, ____ (Client’s Name) would like to participate in activities at the Main Stay Therapeutic Farm. I acknowledge the risks and the potential for risks of horseback riding and other animal related activities. However, I feel that the possible benefits to myself/my son/my daughter/my ward are greater than the risks assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against Main Stay Therapeutic Farm, Inc., its Board of Directors, instructors, therapists, aides, volunteers and/or employees for any and all injuries and/or losses I/my son/ daughter/ward may sustain while participating in a Main Stay Therapeutic Farm, Inc. program. Under the Equine Activity Liability Act, each participant who engages in an equine 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. ~IL PWA-89-0111~

Parent or Guardian


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.

Contact information

Main Stay Therapeutic Farm

6919 Keystone Rd., Richmond, IL 60071

Tel: 815.653.9374  Fax: 815.728.1224

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