Equilibrium Therapeutic Riding: Rider Application Form 2017-2018
Equilibrium Therapeutic Riding offers consistent, individualized and holistic programming. Therapeutic Riding encompasses collectively all horse-related activities for people with disabilities. Emphasis is put on learning functional riding skills for therapeutic purposes.
Basic Registration
1. Client Name *
Your answer
2. Date of Application *
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3. Address *
Your answer
4. City, Province *
Your answer
5. Postal Code *
Your answer
6. Email *
Your answer
7. Phone (Home) *
Your answer
8. Phone (Work)
Your answer
9. Emergency Contact (Name, Phone) *
Your answer
10. Saskatchewan Health Number *
Your answer
11. Parent(s) or Guardian(s), if applicable
Your answer
12. Parent's/Guardian's Address
(if different than Rider's address above)
Your answer
13. City, Province
Your answer
14. Postal Code
Your answer
15.Parent's/Guardian's Email
Your answer
16. Parent's/Guardian's Phone
Your answer
17. Parent's/Guardian's Emergency Contact (Name, Phone)
Your answer
Rider Details
18. Date of Birth *
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DD
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19. Age *
Your answer
20. Height *
Your answer
21. Weight *
Your answer
22. Type of Lesson Requested (check all options that apply) *
A brief discussion with Erin is required in order to determine which options are best for you.
Required
Returning Students
Note: If you are a new student, please skip to the next section.
23. Riding Time
24. In case you need to reschedule, what are your preferred times and days?
Your answer
25. Are there any dates from September 2017 to January 2018 that you know you cannot ride? Please list them here if applicable.
Your answer
26. How do you plan to complete this registration process and payment? *
27. If you responded 'in person' to the question above, how many family members will be attending the customer appreciation BBQ on Sept 5th?
Your answer
New Students
Lessons are typically scheduled for Monday to Friday, noon to supper, and are scheduled on a first-come, first-serve basis.
28. Riding Time: 1st choice
Your answer
29. Riding Time: 2nd choice
Your answer
30. Riding Time: 3rd choice
Your answer
Liability Release
I, Client / Parent / Guardian, would like to participate in the Equilibrium Therapeutic Riding program.

I acknowledge the risks and potential for risk, of horseback riding. However, I feel that the possible benefits to myself / my son / my daughter / my ward are greater than the risk 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 Equilibrium Therapeutic Riding, its owner, Instructors, Therapists, Aides and employees for any and all injuries and / or losses I / my son / my daughter / my ward may sustain while participating in Equilibrium Therapeutic Riding.

31. Signature *
Type your full name (rider over 18 yrs, parent or guardian).
Your answer
32. Date *
MM
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YYYY
Photo Release
I hereby consent to and authorize the use and reproduction by Equilibrium Therapeutic Riding of any and all photographs and / or any other audiovisual materials taken of me / my son / my daughter / my ward, for promotional material, educational activities, exhibitions, or for any other use for the benefit of the program.
33. Signature *
Type your full name (rider over 18 yrs, parent or guardian).
Your answer
34. Date *
MM
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DD
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YYYY
Authorize Consent for Release of Information to Equilibrium Therapeutic Riding Inc. from Other Therapists/Teachers/Facilities
I hereby authorize [ Person or Facility - please indicate below ] to release information from the records of the [ Rider - please indicate name below ]. The information is to be released to Equilibrium Therapeutic Riding for the purpose of developing a Therapeutic Riding Program for the above-named client. The information to be released is detailed below.
35. Authorized Person or Facility *
(Note: Please type N/A if this is not applicable to you.)
Your answer
36. Rider's Name *
(Note: Please type N/A if this is not applicable to you.)
Your answer
37. Information To Be Released (check all options that apply) *
Please send the indicated material to: Equilibrium Therapeutic Riding, c/o Erin McCormick, Box 517 Osler, SK S0K 3A0
Required
38. Signature *
Type your full name (rider over 18 yrs, parent or guardian).
Your answer
39. Date *
MM
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DD
/
YYYY
Information Release
I hereby authorize Equilibrium Therapeutic Riding to release to its instructors and staff, such information as may be necessary to a beneficial and safe riding program.
40. Rider's Name *
Your answer
41. Signature *
Type your full name (rider over 18 yrs, parent or guardian).
Your answer
42. Relation to Rider (if applicable)
Your answer
43. Date *
MM
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DD
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YYYY
Submit
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