AALS/EAL Registration Form 2023

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
2 digit month, 2 digit day, 4 digit yearDate
Photo Release
Photo Release Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Inquiry Information