Guest WaiverPlease enable JavaScript in your browser to complete this form.Contact Info - Step 1 of 4Name *FirstLastDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address *Address Line 1CityIndianaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneEmailParent/Legal Guardian (If under 18)NameFirstLastPhoneNextEmergency ContactsEmergency Contact NameFirstLastEmergency Contact PhonePhysicianPhysician PhonePreviousNextConfidentiality PolicyLoveWay, Inc. staff, volunteers, and visitors will protect the rights and confidentiality of all participants. Medical and personal information regarding participants will be shared only for the purpose of providing safe and effective services. No information regarding a participant is to be shared with others outside of the therapeutic environment at LoveWay, Inc. Discovery of such disclosure may result in the termination of privileges to participate at the Center. Guests are expected to conduct themselves in a respectful manner towards both people and animals at all times. Any violent or disruptive behavior will be cause for dismissal from LoveWay grounds. LoveWay, Inc. is a non‐smoking facility. Discarded tobacco products are hazardous to our horses and a potential fire hazard. Guests under the influence of alcohol or other potentially harmful drugs (prescription or otherwise) will be asked to leave LoveWay’s property.Photo & Media Release: LoveWay, Inc. or local media may use any video/photos of Myself/Participant/Family members during LoveWay, Inc. related activities for promotional, educational, or progam use. *I ConsentI Do Not ConsentConfidentiality Policy: Responsible Party Signature (Parent/Legal Guardian if under 18) * Clear Signature I have read and agree to the Confidentiality Policy.PreviousNextWaiver Agreement & Liability ReleaseMy signature below denotes I agree to all the following as a condition for myself/child/family as it pertains to LoveWay, Inc. (hereafter referred to as the “Center”) as a condition for participation in activities at/on/near the Center’s premises and property or associated with any Center activity including but not limited to equine‐assisted activities, trail riding, arena instruction, barn & pasture activities, demonstrations and public events. WARNING: Under Indiana law, an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities. As the legal representative of the participant (myself/child/family) I acknowledge the risks and potential for risks of equine related activities. I understand not all risks can be foreseen nor prevented. I understand these risks and assume responsibility for them. I hereby, intending to be legally bound for myself/child/family, heirs and assigns, executors or administrators, waive and release forever all claims, liabilities, and damages (present or future) against LoveWay, Inc., its Board of Directors, Executive Director, Instructors, Staff, Therapists, Volunteers and/or other authorized persons for any and all injuries/losses sustained, directly or indirectly, while participating or visiting at LoveWay, Inc. As consideration for the Center to allow myself/child/spouse/family members to engage in Center related activities, I agree to assume full responsibility for any and all bodily injuries, losses, claims, liabilities, or damages, which I or they might sustain. It is mutually understood and agreed the waiver and liability release set forth in this document constitutes a waiver of liability beyond the provisions of the Indiana Equine Activity Liability Act. I further agree to indemnify and hold harmless the Center or persons/entities associated with the Center and to not bring any claim or suit against them on the basis of any exception to the IN Equine Act. Should I breach any part of this waiver/liability release, I agree to pay all the Center’s attorney’s fees or other legal costs that may occur. I attest I am at least 18 years of age, of sound mind, not suffering from shock or under the influence of alcohol, drugs or intoxicants. I have read this ENTIRE waiver and application and fully understand it. I intend for this waiver, agreement and liability release to be valid and binding today and at ALL FUTURE TIMES. I attest that all the information I have provided in this application/medical history is true and accurate.Waiver Agreement & Liability Release: Responsible Party Signature (Parent/Legal Guardian if under 18) * Clear Signature Submit