AALS/EAL Registration Form 2023

Registering for (please mark all that apply)*

Animal Assisted Life SkillsEquine Assisted Learning
Participant 1*

First NameLast Name
Age 1
Participant 2

First NameLast Name
Age 2
Participant 3

First NameLast Name
Age 3
Participant 4

First NameLast Name
Age 4
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:*

Area CodePhone Number
Email (@arizona emails are not accepted)*
example@example.com
Military Family?*

YesNo
Job Title (Optional):
Emergency Contact #1

First NameLast Name
Emergency Phone Number #1

Area CodePhone Number

Medical Information

Insurance information is required
Hospital/Clinic Preference
Physician's Name
Physician's Phone Number

Area CodePhone Number
Insurance Company*
You MUST have Insurance to volunteer
Policy Number*
You MUST have Insurance to volunteer
Do you have any allergies? If yes, please explain*
Do you take any medications that could impair your decision making or movement?*
Write N/A if not applicable to your registration.
Anything else that we should know about you?
Whom may we thank for your referral?
Where did you hear about TRAK?*

Release of Liability and Waiver

This form is mandatory.
Rillito River Ranch Waiver. Your signature below acts as your agreement to this waiver.
Therapeutic Ranch for Animals and Kids Waiver and Media Release
List all participants covered by these liability releases*
Waiver Signature*
Date*

MonthDayYear
Date
Photo Release*
Photo Release Signature*
Date*

MonthDayYear
Date

Inquiry Information