Consent for Release of Information

I,

Choose one *

Rider
Parent
Guardian

, do here by give consent to

Provider *

, to provide any and all necessary information on

Rider’s name *

to Thorncroft Equestrian Center

personnel for the determination of appropriateness of continued participation in the equine-assisted therapy program.

It is my understanding that all information released to Thorncroft Equestrian Center will be held in the strictest of confidence and no information will be released to any unnecessary personnel or outside individuals.

All information will be kept in the rider’s file under lock and key in the front office.

This release is valid for one (1) year from date of signature.

Signature *

"By filling out your full name here, you are e-signing this document"

Choose One *

Rider
Parent
Guardian

Date *