Forward Stride Vaulting Program Application
Participant First Name
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Participant Last Name
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Name of parent/guardian/caregiver:
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Relationship to Participant:
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Best phone #:
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Email for program information:
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Complete Address:
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Participant Date of birth:
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Participant Gender:
Participant Height:
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Participant Weight:
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Diagnosis:
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Date of Onset
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Other Medical Conditions or Allergies:
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Temporary or chronic injuries
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Physician's Name
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Physician's Phone #
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Preferred Hospital
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Do you have any prior vaulting experience?
Do you have any fear of horses or other animals that we should know about? If so, please explain below.
Your answer
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.
Participant or Participant's Parent/Guardian Electronic Signature
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Date Signed
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