Equilibrium Therapeutic Riding: Rider Application Form 2019/2020
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.

Please check off each item to acknowledge that you have read and understand the following
policies:

Application process:
The following application process MUST be completed prior to the student’s first ride:
1) Application form completed and submitted
2) Additional medical forms completed and submitted (atlanto-axial verification for riders with Down's syndrome)
3) Acknowledgement of Risk Form read, signed and submitted
4) Post-dated cheques submitted for the full riding session, dated for the first of every month & made payable to Equilibrium Therapeutic Riding. For individuals who rely on funding through an outside agency, the individualized payment plan must be clearly outlined by email to erin_mccormick@msn.com prior to the first lesson. Applications are only valid for one riding session and must be resubmitted each spring and fall in order to continue riding at Equilibrium Therapeutic Riding.

Attendance at lessons:
Equilibrium Therapeutic Riding offers consistent, individualized and holistic programming. In
order to best serve individuals, lessons are offered on a weekly basis. Therapeutic gains, and
success with any program for any individual, take time and commitment. Therefore, faithful
attendance at the weekly riding lessons is absolutely required! A total of 2 absences/10 month
riding session for any reason not discussed prior to acceptance into the riding program could lead
to dismissal from the program and the student will not be permitted to ride at Equilibrium
Therapeutic Riding for the remainder of the riding session. (Extenuating circumstances such as
surgery/medical procedures will be taken into consideration.)
Regulations *
Required
If you are in agreement with the program requirements & regulations above, please proceed to the application form below. If you have any questions or concerns, please address them with Erin McCormick prior to applying.
Basic Registration
1. Client Name *
2. Date of Application *
MM
/
DD
/
YYYY
3. Address *
4. City, Province *
5. Postal Code *
6. Email *
7. Phone (Home) *
8. Phone (Work)
9. Emergency Contact (Name, Phone) *
10. Saskatchewan Health Number *
11. Parent(s) or Guardian(s), if applicable
12. Parent's/Guardian's Address
(if different than Rider's address above)
13. City, Province
14. Postal Code
15.Parent's/Guardian's Email
16. Parent's/Guardian's Phone
17. Parent's/Guardian's Emergency Contact (Name, Phone)
Rider Details
18. Date of Birth *
MM
/
DD
/
YYYY
19. Age *
20. Height *
21. Weight *
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
Clear selection
24. If you have answered that you have a potential conflict, what are your preferred times/days?
25. Are there any dates from July 2 to August 28, 2020 that you know you cannot attend your lesson?
26. How do you plan to complete this registration process and payment? *
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
29. Riding Time: 2nd choice
30. Riding Time: 3rd choice
Liability Release
I 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).
32. Date *
MM
/
DD
/
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).
34. Date *
MM
/
DD
/
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.)
36. Rider's Name *
(Note: Please type N/A if this is not applicable to you.)
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).
39. Date *
MM
/
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 *
41. Signature *
Type your full name (rider over 18 yrs, parent or guardian).
42. Relation to Rider (if applicable)
43. Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This form was created inside of Territorial. Report Abuse