Forward Stride Vaulting Program Application
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: *
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Participant Gender:
Clear selection
Participant Height: *
Participant Weight: *
Is there a diagnosis? *
If yes please explain.
Date of Onset
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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?
Clear selection
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.
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 *
Date Signed *
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