Participant's Application & Health History

Participant(Required)

Date of Birth(Required)

Age(Required)

Height(Required)

Weight(Required)

Gender(Required)

Male

Female

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Preferred Phone(Required)

Alternative Phone

Email(Required)

How did you hear about the program?(Required)

School / Employer

Employer/School(Required)

Employer/School Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employer/School Phone(Required)

Parent/Legal Guardian

Parent/Legal Guardian Name(Required)

Parent/Legal Guardian Address (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Legal Guardian Phone

Caregivers(Required)

Please list Name and Phone #

Abilities/Difficulties

Describe your abilities/difficulties in the following areas (include assistance required or equipment needed):

PHYSICAL FUNCTION (e.g., mobility skills such as transfers, walking, wheelchair use, driving/bus riding)(Required)

PHYCHOLOGICAL FUNCTION (e.g., work/school including grade completed. leisure interests, relationships, family structure, support systems, companion animals, fears/concems, etc.)(Required)

GOALS (i.e., why are you applying for participation? What would you like to accomplish?(Required)

Signature(Required)

(If student is under age of 18 years old this must be signed by a legal guardian)

Date

Photo Release

Photo Release(Required)

I do

I do NOT

consent to and authorize the use and reproduction by (center) of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.

(Center)

Signature(Required)

(If student is under age of 18 years old this must be signed by a legal guardian)

Date

(Optional)

For demographic data collection only, please check the ethnicity you most identify with:

Ethnicity

Caucasian

African American

Hispanic

Middle Eastern

Asian

Multi- Racial

Other

Emergency Treatment Release Form

Consent Plan and Agreement

Initial

(initial) In the event emergency medical aid/treatment is required due to illness or injury while being on the of the agency. I authorize HORSEPOWER Inc. to 1: Secure and retain medical treatment and transportation and 2: Release records upon request to the authorized individual or agency involved in the medical emergency This authorization includes x ray, surgery. hospitalization, medication, and any treatment procedure deemed by the physician. This provision will only be evoked if the person(s) below is/are unable to be reached.

Signature

(If student is under age of 18 years old this must be signed by a legal guardian)

Date

Procedure:

OR Non-Consent plan

Initial

(initial) I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the of receiving services or while being on the property of the agency.

Non-Consent plan

Parent or guardian will remain on site at all times during equine assisted activities

In the event emergency treatment/aid is required, I wish the following procedure to take place

Liability Release

Enter Client's Name(Required)

(Client's Name) would like to participate in the HORSEPOWER Inc. program. I acknowledge the risks and potential for risk of horseback riding. However, I feel that the possible benefits to me/my son/my daughter/my ward are greater than the risk assumed. I hereby, intending to be legally bound, for me, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against HORSEPOWER Inc., its Board of Directors, instructors, therapists, aids, volunteers and/or employees for any and all injuries and/or losses I/my son/ my daughter/my ward while in HORSEPOWER Inc.

Signature(Required)

(If student is under age of 18 years old this must be signed by a legal guardian)

Date

Emergency Contact

Emergency contact name:(Required)

First Last

Phone

Emergency contact name:

First Last

Phone

Warning Under North Carolina law, equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting exclusively from the inherent risks of equine activities. Chapter 99E of the North Carolina General Statutes. 4537 Walpole Rd. High Point, NC 27265 - phone (336)931-1424 - fax (336)905-6936

* By clicking "Submit" I agree my electronic signature and initials have the same force and effect as my written signature or initial.