Equine Facilitated Learning (EFL) Registration
Client First Name: *
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Client Last Name: *
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Address: *
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Best Phone Number: *
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Secondary Phone Number:
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Best Email Address: *
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Secondary Email Address:
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Client Birthday: *
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Client Height: *
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Client Weight: *
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Client Diagnoses: *
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Other Medical Conditions or Allergies:
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Name of parent/guardian/caregiver: *
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Relationship to Participant:
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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.
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Are you interested in the Horses 101 Class?
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.
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Do you have any prior horse experience?
Do you have any fear of horses or other animals that we should know about? If so, please explain below.
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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 *
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Date Signed: *
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