Forward Stride Riding Program Application
Participant First Name *
Participant Last Name *
Name of parent/guardian/caregiver: *
Relationship to Participant: *
Best phone #: *
Email for program information: *
Mailing Address: *
Participant Date of birth: *
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Participant Gender: *
Participant Height: *
Participant Weight: *
Is there a diagnosis? *
Required
If yes please explain.
Date of Onset *
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Other Medical Conditions or Allergies: *
Emergency Contact Name: *
Emergency Contact Number: *
Reason(s) for Participation *
Required
Details regarding your reasons for participation
It may help us place you more quickly in our program if we can place you with other participants of similar abilities. Please provide as much detail as possible.
Physician *
Physician's Phone # *
Preferred Hospital *
What times are you generally available for our services?
Please be as specific as possible and include all options. This information will be used if we have an opening in an appropriate group class or in an instructor's schedule and may move you off of the wait list more quickly.
Are you a Veteran?
If yes are you interested in Forward Stride's Horsemanship for Military Veterans Program?
Do you have any prior riding experience?
Clear selection
If you have prior riding experience, what gaits are you comfortable riding at?
If you have prior riding experience, where did you ride before?
What was your reason for discontinuing?
Would you prefer to ride English or Western? *
Would you prefer to ride in a private or group setting? *
Do you have any fear of horses or other animals that we should know about? If so, please explain below.
Do you have any special needs regarding mobility or independence? *
If "other" please explain, special needs regarding mobility or independence?
Liability release to be signed by participant or parent/guardian if participant is under 18 years of age. *
I verify that I am over the age of 18 or the parent/guardian of the above participant who is a minor.
Liability Release *
I acknowledge the many and serious risks and potential risks associated with horse activities. However, I feel that the possible benefits to myself, my son/daughter, my ward, my horse and the clients are greater than the risks assumed. As a condition of participation, I hereby, intending to be legally bound, for myself, my son/daughter, my ward, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against Forward Stride, their Directors, Officers, Instructors, Therapists, Aides, Volunteers, Horse Owners and/or Employees for any and all injuries and/or losses I, my son daughter, my ward, my horse may sustain while participating in Forward Stride activities, except for injuries or losses caused intentionally or by willful or wanton disregard for safety.
Required
Participant or Participant's Parent/Guardian Electronic Signature *
Date Signed *
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