Please print and bring with you on the first day!
No campers will be permitted to attend without these forms



Round-Up H.O.P.E.
35105 Calle La Coca
Temecula, CA 92592
951-757-3424
www.rounduphope.com

Participants/Volunteers/ Guests/Staff/ Relatives Release and Hold Harmless Agreement

This release limits our liability. Read it!!!

By signing this form, I acknowledge that therapeutic and pleasure horse back riding is a dangerous activity,
which may result in injury to me or my horse or in damage to my equipment. With this knowledge, in my
consideration for services for Round-Up H.O.P.E. and as inducement for the services from Round-Up H.O.P.
E. to provide therapeutic and or pleasure riding to me, I hereby waive, release, discharge, and hold
harmless Round-Up H.O.P.E., its officers, directors, employees, and volunteer assistants, their heirs,
executors, administrators, successors, or assigns from any and all liability for damages sustained by me,
any animal owned or controlled by me, or for any item personally under my dominion and control. Without
limiting the generality of the above. I hereby waive and release Round-Up H.O.P.E., its officers, directors,
and all volunteers’ assistants for liability based on the active or negligence of said persons and entities.

I hereby agree to indemnify and hold harmless Round-Up H.O.P.E., The Alfino Family, its officers, directors,
staff and all volunteer assistance associated therewith for any claims which may be made against them
including attorney’s fees and cost of suit in any action based upon or arising from my acts or omissions, or
the actions of any animal within my control.

This release extends to all claims, whether presently know or unknown. I hereby expressly waive any
benefits I may have pursuant to section 1542 of the California civil Code relating to the release of unknown
claims, which provides:

“A general release does extend to claims which the creditor does not know or suspect to exist in his favor at
the time of executing the release which if known by him must have materially affected his settlement with the
debtor.”

I acknowledge that I have read the foregoing and understand the contents thereof.

I understand and agree that I will not bring any unauthorized visitors and/or family members or friends to
Round-Up H.O.P.E. without prior authorization. All authorized visitors must have completed forms and have
read and signed ranch rules and volunteer training/safety regulations. No persons shall bring pets, dogs or
unauthorized visitors to Round-Up H.O.P.E. Please adhere to all posted signs. Round-Up H.O.P.E. will not
be responsible for any unsupervised children. All visiting children need adhere to rules and regulations. No
persons shall be in the arena or barn area without supervision-meaning a staff member or authorized
volunteer must be present. All visiting parties must notify
Laura, Steve or Courtney Alfino that they are planning to visit the ranch. No persons with prior existing
medical conditions that could be exacerbated by dirt, flies, mosquito’s, bees, yellow jackets, animal
dandruff, allergies, scratches or scrapes should not be brought to Round-Up H.O.P.E. This release also
holds harmless any claims to damage done to vehicles or other personal property.

Dated:____________________Signature:___________________________________________

Print Name:____________________________




Round-Up H.O.P.E., Inc.
35105 Calle La Coca
Temecula, CA 92592
951-757-3424
www.rounduphope.com
rounduphope@msn.com


Parents Name:_____________________________Cell Number:_____________________________

Students Name:______________________Age:______DOB:_______Allergies:_________________

Students Name:______________________Age:_______DOB:_______Allergies:_________________

Students Name______________________Age:________DOB:_______Allergies:_________________

Address:________________________:City:___________________State:_____Zip Code:__________

Medical Informtion:__________________________________________________________________

Email:____________________________________________

Emergency Contact:_________________________________Phone Number:____________________

Medical Insurance Provider:__________________________Preferred Medical Facility:_____________

Policy#_____________________________________GroupNumber:______________________________

Insurance Company Phone Number:_______________________

Primary Insured Name on Policy      :___________________________________

In the event of emergency aid/treatment is required due to illness or injury during the process of receiving
services, or while being on the property of the agency, I authorize__________________________to:

1.        Secure and retain medical treatment and transportation if needed.
2.        Release client records upon request to the authorized individual or agency involved in the medical
emergency treatment.

Consent Plan

This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed
“life saving” by the physician. This provision will only be invoked if the persons above is unable to be
reached.

Photo Release:

I DO            DO NOT

Consent to and authorize the use and reproduction by Round-Up H.O.P.E. of any and all photographs and
any other audio/visual materials taken of me or my children for promotional, educational, exhibitions or for
any other use for the benefit of the program.

Signature:________________________________Date:_____________________