Participant Application

Participant Application
Name

First Name Last Name
Sex
DOB

Month Day Year
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.)
Medical Information
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

Month Day Year
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:

Vision Hearing Sensation Communication Heart Breathing Digestion Elimination Circulation Emotional/Mental Health Behavioral Pain Bone/Joint Muscular Thinking/Cognition
Special Needs Detail
Please provide detail on checked boxes above
Last Tetanus Shot

Month Day Year
Date
Abilities

Describe your abilities/challenges 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)
Psychosocial Function
(e.g., school including grade completed, leisure interests, relationships-familystructure, support systems, companion animals, fears/concerns, etc.)
Releases
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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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.
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Participant Application

Medical Information

Abilities

Releases