Forward Stride Vaulting Program Application

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Forward Stride currently offers Competitive Vaulting

Participant First Name *

Participant Last Name *

Name of parent/guardian/caregiver:

Relationship to Participant:

Best phone #:

Email for program information:

Complete Address:

Participant Date of birth: *

YYYY

Participant Gender:

Male

Female

Prefer Not To Say

Other:

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Participant Height: *

Participant Weight: *

Is there a diagnosis? *

Yes

If yes please explain.

Date of Onset

YYYY

Other Medical Conditions or Allergies:

Any temporary or chronic injuries?

Do you have any special needs regarding mobility or independence?

Emergency Contact Name: *

Emergency Contact Phone Number. *

Physician's Name

Physician's Phone #

Preferred Hospital

Do you have any prior vaulting experience?

Yes

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What times are you generally available for our services? *

Do you have any fear of horses or other animals that we should know about? If so, please explain below.

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.

I am over the age of 18.

I am 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.

I accept and agree to the above statement.

I DO NOT accept or agree to the above statement.

Participant or Participant's Parent/Guardian Electronic Signature *

Date Signed *

YYYY

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This form was created inside of Forward Stride.