Waiver - General - Healing Hooves

Healing Hooves Equine Facilitated Wellness and Animal Assisted Therapy

Training, Mentoring and/ or Personal Growth

Delivered online and/ or onsite

Waivers

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I,
Participant’s name*
First Last
would like to participate in the program(s) as detailed above with Susan McIntosh and the Healing Hooves Animal Assisted and Equine Facilitated Wellness, Counselling and Training Program. I acknowledge the risks and potential for risk of both being around and interacting with horses and with other animals and in participating in professional training within an online and onsite format. However, I feel that the possible benefits to myself are greater than the risks assumed.
I consent to be contacted by, and to communicate with, Susan McIntosh and her delegates through the online training platform and/ or by phone/ e-mail/ video conferencing, and/ or text at the contact numbers and e-mail addresses that I provide. I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected electronic communications as described in this document. I understand and accept the risks outlined in this document, associated with the use of the electronic communications with Susan McIntosh and her delegates. I consent to the conditions and will follow the instructions outlined as well as any other conditions that Susan McIntosh and her delegates may impose regarding electronic communications. I acknowledge and agree to communicate with Susan McIntosh and her delegates using these electronic communications with a full understanding of the risks in doing so. I confirm that any questions that I had regarding the provision of services through electronic communications have been answered by Susan McIntosh and/or her delegates.
I confirm I have read, understood and agree to follow the Healing Hooves COVID 19 detailed protocols as detailed in this document. I confirm that I understand the risks of contraction of COVID-19 and/or any other illness, infectious disease or otherwise transmittable diseases.
I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims against, and agree to indemnify and hold harmless, Susan McIntosh, Robert McIntosh, Maren McIntosh, Healing Hooves, and their counsellors, instructors, staff, volunteers, their heirs, successors, administrators, assigns or employees, individually and collectively, for any and all injuries and/or losses or harm I sustain while and/ or as a result of participating or interacting with Susan McIntosh, her delegates and/or Healing Hooves programs.
Participant Signature*
Date*
MM slash DD slash YYYY
Witness Signature*
Date*
MM slash DD slash YYYY

Authorisation for Emergency Medical Treatment
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
DOB*
MM slash DD slash YYYY
Emergency Contacts: (Name – Relation - Phone)
Emergency contact 1:*
Emergency contact 2:*
Physicians Name and phone number:*
Personal Health Number:*
Allergies to Medications:*
Current Medications:*
Side effects of Current Medications:*
In the event emergency medical aid/ treatment is required due to illness or injury during the process of attending workshops or sessions facilitated by Susan McIntosh or her delegate, I authorize Susan/ her delegate to:
1. Secure and retain medical treatment and transportation if needed, and
2. Release records upon request to the authorized individuals or agency involved in the medical emergency treatment.
This authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedure deemed ‘life saving’ by the physician.
Participant Signature*
Date*
MM slash DD slash YYYY
Witness Signature*
Date*
MM slash DD slash YYYY

Risks and Conditions of Using Electronic Communication

1. Risks of using electronic communication: While the Susan McIntosh (the Service Provider) will use reasonable means to protect the security and confidentiality of information sent and received using electronic communications, because of the risks outlined below, the Service Provider cannot guarantee the security and confidentiality of electronic communications:
- Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.
- Despite reasonable efforts to protect the privacy and security of electronic communication, itis not possible to completely secure the information.
- Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
- Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings.
- Electronic communications are subject to disruptions beyond the control of the Service Provider that may prevent the Service Provider from being able to provide services
- Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Service Provider or the Client.
- Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.
- Electronic communications may be disclosed in accordance with a duty to report or a court order.
- Videoconferencing using no cost, publicly available services may be more open to interception than other forms of videoconferencing
  There may be limitations in the services that can be provided through electronic communications, dependent on the means of electronic communications being utilized
- Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.
- Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.
2. Conditions of Using Electronic Communications:
- While the Service Provider will endeavour to review electronic communications in a timely manner, the Service Provider cannot provide a timeline as to when communications will be reviewed and responded to. Electronic communications will not and should be used for medical emergencies or other time-sensitive matters.
- Electronic communication may not be an appropriate substitute for some services that the Service Provider offers.
- Electronic communications may be copied or recorded in full or in part and made part of your clinical chart. Other individuals authorized to access your clinical chart, such as staff and billing personnel, may have access to those communications.
- The Service Provider may forward electronic communications to staff and those involved in the delivery and administration of your care. The Service Provider will not forward electronic communications to third parties, including family members, without your prior written consent, except as authorized or required by law.
- Prior to the commencement of the provision of services by the Service Provider through electronic communications, the Service Provider and the Client will establish an emergency protocol to address the following: o Steps to be followed in the event of a technical isSusan that causes a disruption in the services that are being provided by the Service Provider; and o Steps to be followed in the event of a medical emergency that occurs during the provision of services.
- The Service Provider is not responsible for information loss due to technical failures associated with your software or internet service provider
- The Client will inform the Service Provider of any changes in the Client’s email address, mobile phone number, or other account information necessary to communicate electronically.
- The Client will ensure the Service Provider is aware when they receive an electronic communication from the Service Provider, such as by a reply message or allowing “read receipts” to be sent.
- The Client will take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.
- If the Client no longer consents to the use of electronic communications by the Service Provider, then the Client will provide notice of the withdrawal of consent by email or other written communication.
- Consent*
  I agree to the above statements
- Email

Authorisation for Emergency Medical Treatment

Canada
Province of Alberta
OFFICIAL OATH OF CONFIDENTIALITY

PHOTO RELEASE

COVID 19 Protocol for Training Participants – updated May 2022

Risks and Conditions of Using Electronic Communication

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Authorisation for Emergency Medical Treatment

Canada Province of Alberta OFFICIAL OATH OF CONFIDENTIALITY

PHOTO RELEASE

COVID 19 Protocol for Training Participants – updated May 2022

Risks and Conditions of Using Electronic Communication

Pin It on Pinterest

Canada
Province of Alberta
OFFICIAL OATH OF CONFIDENTIALITY