Participant Application

Name

First Name Last Name

Sex

DOB

Date

Primary Caregiver

First Name Last Name

Secondary Caregiver

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Area Code Phone Number

Email

example@example.com

Referral Source

School

Preferred Contact Method

Shirt Size

Home Situation

(i.e. who lives at home, parents, siblings, pets, extended family relationships, etc.)

Primary Physician

Physician's Clinic

Physician's Phone

Area Code Phone Number

Hospital Preference

Emergency Contact

Emergency Contact Relationship

Emergency Contact Phone

Area Code Phone Number

Diagnosis

Date of Onset

Date

Height

Weight

Allergies

Medications

include prescription, over-the-counter, name, dose and frequency

Seizure Risk

Shunt Risk

Seizure/Shunt Details

Down Syndrome Atlantoaxial Instability

Braces/Devices

Braces/Devices Detail

Please indicate with a check current or past special needs in the following areas:

Special Needs Detail

Please provide detail on checked boxes above

Last Tetanus Shot

Date

Physical Function

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

Psychosocial Function

(e.g., school including grade completed, leisure interests, relationships-familystructure, support systems, companion animals, fears/concerns, etc.)

PHOTO RELEASE I consent to and authorize the use and reproduction by Inspiration Stables, Inc. of any and all photographs, videos and any other audio/visual materials taken of me for promotional material, education activities, exhibitions, marketing,advertising, social media or for any other use for the benefit of the program. (must be signed by parent or guardian if under age 18)

I DO I DO NOT

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MEDIA DISCLOSURE This disclosure is to inform you of Inspiration Stables’ policy for use of photography and videos with our facilities to comply with HIPAA laws. Clients may be photographed or videotaped by their parents/caregivers. If there is any potential for other clients to be viewed, then videotaping and/or taking pictures is prohibited. If these pictures or videos are utilized inappropriately once in the possession of the individual taking the video/photo, Inspiration Stables shall not be held accountable. I understand and have read the above statement in its entirety.

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LIABILITY RELEASE WAIVER AND INFORMED CONSENT TO PARTICIPATE IN INSPIRATION STABLES, INC. EQUESTRIAN ACTIVITIES State of Iowa Equine Liability Form Rev 2007 NOTICE:Please read this document before signing. Signing this document affirms that you have read it and understand it in its entirety. The Equine Activity Liability laws of the State of Iowa,§ 673.3, state among its statutory provisions: “Warning: Under Iowa Law, a domesticated animal professional is not liable for damages suffered by, an injury to, or the death of a participant resulting from the INHERENT RISKS of domesticated animal activities, pursuant to Iowa Code Chapter 673. You are assuming the inherent risks of participating in this domesticated animal activity. A number of inherent risks are associated with a domesticated animal activity. A domesticated animal may behave in a manner that results in damages to property or an injury or death to a person. Risks associated with the activity may include injuries caused by bucking, biting, stumbling, rearing,trampling, scratching, pecking, falling, or butting. The domesticated animal may react unpredictably to conditions, including, but not limited to, a sudden movement, loud noise, an unfamiliar environment, or the introduction of unfamiliar persons, animals, or objects. The domesticated animal may also react in a dangerous manner when a condition or treatment is considered hazardous to the welfare of the animal; a collision occurs with an object or animal; or a participant fails to exercise reasonable care, take adequate precautions, or use adequate control when engaging in a domesticated animal activity, including failing to maintain reasonable control of the animal or failing to act in a manner consistent with the person's abilities. Inspiration Stables, Inc.P. O. Box 16, Peosta, IA 50268 Tel (563) 265-1780 I, the undersigned, having read and understood the content of this document, agree and consent to the provisions contained herein.It is my intention and desire to participate in equestrian-related activities including but not limited to, riding, horse-handling/leading, grooming, groundwork, side-walking, mounted games, chores, instructing, training, facilitating,or being present at equestrian activities as an observer or other activity related, however slight, to equestrian activities at events held by Inspiration Stables, Inc. I hereby acknowledge that I am fully aware of the nature, purpose and risks of equine activities of Inspiration Stables, Inc. I acknowledge that these activities are potentially dangerous and that I voluntarily accept any of the inherent risks involved. In consideration for my being permitted to take part in these activities, I agree to be bound by the rules of Inspiration Stables, Inc. and to obey the directions of the instructors and other governing officials of activities. In the event of any disagreements, claims or disputes arising from my taking part in these activities, I agree to submit such disagreements or disputes to a board of arbitration appointed by Inspiration Stables, Inc. and abide by any decisions reached by such board. I agree to release, protect, defend, hold harmless, and indemnify Inspiration Stables,Inc., its organizers and agents, officials, servants, and representatives from and against all claims, actions, costs, expenses, including reasonable attorney fees and demands with respect to death, injury, loss or damage to my person or property, howsoever caused, arising out of or in connection with my taking part in these events even if the same may have been contributed to or occasioned by the negligence of the said Inspiration Stables, Inc. or any of its agents,servants, or representatives. It is understood and agreed that this agreement is to be binding upon myself, my heirs, executors, personal representatives and assigns under the laws of the State of Iowa related to Equine Activity Liability. If any term or clause of this Agreement is to any extent invalid, illegal or incapable of being enforced,such term or clause shall be excluded to the extent of such invalidity,illegality or unenforceability; all other terms and clauses herein shall remain in full force and effect.I UNDERSTAND THAT THIS IS A LEGAL DOCUMENT. I HAVE READ AND UNDERSTOOD THIS RELEASE AND I UNDERSTAND ALL ITS TERMS. I EXECUTE IT VOLUNTARILY AND WITH FULL KNOWLEDGE OF ITS MEANING AND SIGNIFICANCE. I HEREBY ASSUME ALL OF THE RISKS ASSOCIATED WITH EQUINE RELATED ACTIVITIES.

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I acknowledge receipt of Inspiration Stables' policy information. I understand it is my responsibility to read,understand, and comply with Inspiration Stables' policies. By my signature below, I agree to comply with Inspiration Stables'policies and understand that violation(s) of policy could result in disciplinary action, up to and including mytermination from Inspiration Stables.

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I,_______________________________, am aware of the risks of contracting or spreading Covid-19 while working or volunteering at Inspiration Stables, Inc.;attending an event; and/or receiving face-to-face services from Inspiration Stables, Inc. during the time of a pandemic outbreak, and/or Iowa Governor’s or Dubuque County’s proclamation of restrictive measure(s). I am aware that face-to-face services and experiences increase my risk of contracting and passing on the Covid-19 or Coronavirus and agree to hold harmless Inspiration Stables, Inc. and its residents, members, officers, managers, agents, employees and all other individuals I may come in contact with during this interaction and receiving of services, providing services, attending an event or volunteering within this organization. I am aware of the options that may be available for remote services including, telephonic and video services during this Pandemic outbreak. I agree to and will follow all guidelines for personal hygiene, personal safety and public safety as recommended by Inspiration Stables, Inc.; as well as my individual provider/practitioner. This may include, but is not limited to, waiting in my vehicle and/or home until I am asked to enter the building/farm; maintaining social distance; washing my hands prior to and following each session or activity; use of hand sanitizer upon request; wiping down surfaces with disinfecting wipes and/or wearing a protective medical mask and/or gloves. I agree to stay home and/or cancel my services should I have personally exhibited or have been in contact with someone who has presented with illness within the previous 24 hours to 2 weeks, including; cough, sneezing, fever, chest congestion or additional signs of potential spread of any virus or bacteria/disease. In addition, I will follow the recommendations of my provider once I have notified them of these risks in regards to my future services or attendance during this pandemic. Inspiration Stables, Inc. will engage in regular cleaning and sanitizing of the facility, horse tack, grooming supplies and office, doors, and frequently touched areas in-between clients and on a daily basis as recommended by the CDC for the safety of clients, employees, volunteers and horses. I am signing under my own free will and agree to follow these and hold harmless all individuals associated with or through my services acquired from Inspiration Stables, Inc. BY SIGNING BELOW, I CONFIRM THAT I HAVE READ AND UNDERSTAND THIS DOCUMENT. *In the event that the undersigned is under the age of 18, the signature of a parent or guardian is required.

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Upon receipt and review of your application, we will contact you via email with forms that need to be completed by your child's primary care physician in order to complete your enrollment.

Participant Application

Medical Information

Abilities

Releases