StirrUp Purpose Therapeutic Horsemanship Application

StirrUp Purpose

at Faith Run Farms

60575 Billadeau Rd, Bend OR 97702

541-410-0164
Horsemanship Student Application

Please let us know a little about you!
Participant Name

First NameLast Name
MinorIndependent AdultAdult with Legal guardian
If the Participant is a minor or an adult with a legal guardian, please complete the following information for the participant. If the participant does not have phone or email, please enter parent or legal guardian contact information.
Parent/Guardian Name

First NameLast Name
Participant Date of Birth*

DayMonthYear
Participant Age*
Participant Gender*
Participant Phone Number*
Format: (000) 000-0000.
YesNo
Participant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Email*
example@example.com
Participant Height (ft.inches)*
Participant Weight (lbs)*
Participant School/Institution/Employer:*
IEPIFSP504 planNA
Please provide an updated copy

Cancelof
VeteranActive MilitaryFirst ResponderNone of the above
NoneOne time pony, sleigh or trail rideSome riding lessons/beginnerIntermediate riderAdvanced/Experienced riderOther
Tell us about any physical limitations or conditions we should be aware of while working with the Participant:
Please tell us about any behavioral health, sensory or cognitive conditions we should be aware of while working with the Participant:
YesNo
If yes, define:
Tell us about your goals for participating?*
Monday morningMonday afternoonMonday eveningTuesday morningTuesday afternoonTuesday eveningWednesday morningWednesday afternoonWednesday eveningThursday morningThursday afternoonThursday eveningFriday morningFriday afternoonSaturday morningSaturday afternoonSunday afternoon
I do hereby attest that this information is true, accurate and complete to the best of my knowledge.
Current or past participantWebsite/Social MediaCommunity OrganizationOther
HOLD HARMLESS AGREEMENT/RELEASE AND WAIVER OF LIABILITYStirrUp Purpose
I have chosen to participate in equine-related activities directed by StirrUp Purpose including but not limited to riding, volunteering, teaching, training, ground work, grooming and ranch work (the “Activities”). In consideration for StirrUp Purpose allowing me and/or my family, as applicable, to participate in the Activities, to the fullest extent permitted by law, on behalf of myself or my minor children, I hereby voluntarily acknowledge, agree, and contract as follows:
Signature of Participant or Legal Guardian of Participant*

Clear
Signature of Participant or Legal Guardian of Participant (typed name indicates signature):*
Date*

MonthDayYear
Date
Email
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone:*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Student:
Should be Empty:

Horsemanship Student Application

HOLD HARMLESS AGREEMENT/RELEASE AND WAIVER OF LIABILITYStirrUp Purpose