L.U.C.Y Youth Program Registration Form

Date:*

Date

Legal name of participant:*

First NameLast Name

Preferred name/pronouns of participant:

Participant's date of birth:*

Date

Participant's phone Number(s):

Parent/Guardian Name:*

First NameLast Name

Parent/Guardian Phone Number(s):*

Email:*

example@example.com

Address:*

Street Address

Street Address Line 2

CityProvince

Postal

Health Card Number of participant: blanks* Expiration Date: blank*

Goal for equine therapy (example physical, emotional, behavior, riding skills, etc). Please be specific. *

Participant's medical history primary diagnosis:*

Participant's secondary diagnosis (if applicable):

Participant's height:*

Participant's weight:*

Participant's sex:*

Does the participant have seizures? If yes, please describe the frequency.*

Is the participant on any medications? If yes, please list the medications and what they're used for.*

Does the participant have any allergies? If yes, please include details.*

Can the participant walk?*

YesNo

Does the participant walk with:*

Lots of helpLittle helpNo help

Does the participant user a wheelchair?*

YesNo

Does the participant have a weaker side?*

YesNoNot sure

If the participant does have a weaker side, which side?

LeftRight

What is the participant's muscle tone in their upper extremities?*

PoorGoodExcellent

What is the participant's muscle tone in their lower extremities?*

PoorGoodExcellent

What is the participant's muscle tone in their trunk?*

PoorGoodExcellent

How is the participant's balance when sitting?*

PoorGoodExcellent

How is the participant's balance when standing?*

PoorGoodExcellent

Sight:*

Hearing:*

Tactile:*

Please describe the participant's level of continence:*

Anything else we should know about the participant?

Has the participant undergone surgery? If yes, please include the date(s).*

Parents and/or Guardians must sign a release after each surgery in order for riders to participate in therapeutic riding.*

I agree

PHOTO RELEASE: do you give L.U.C.Y permission to take pictures of the participant for specific uses in publications, bulletin boards, general display, or social media?*

YesNo

Signature of parent/guardian:*

Date signed:*

Date

Signature:*

The L.U.C.Y. Therapeutic Riding Association will be referred to as “L.U.C.Y”. Reaching Strides Equestrian Centre will be referred to as RSEC. The undersigned acknowledges that equine activities undertaken at the facility and grounds of Reaching Strides Equestrian Centre (RSEC), (the home of LUCY) have inherent risks. L.U.C.Y. and RSEC will endeavor to provide reasonable services and to act reasonably, although L.U.C.Y. and RSEC is not able to assure you that the services they, or anyone else at the facility L.U.C.Y. and RSEC provides or, the horses and animals at L.U.C.Y. and RSEC will meet your needs or provide a trouble free or risk free experience. The undersigned releases L.U.C.Y. and RSEC its agents and employees from all liability and waives, as against the L.U.C.Y. and RSEC its agents, employees, volunteers, and all resources, causes of action or claims of any kind for loss or damages, including any consequential loss or damage, and voluntarily accepts the legal risk, thereby expressly giving up any right of action from the physical risk arising from any actions initiated by the undersigned or, by anyone who is not affiliated with the L.U.C.Y. and RSEC., who is acting on the undersigned’s behalf. The undersigned further acknowledges and agrees that: Equestrian activities can be very dangerous and expose all participants to many risks and hazards, some of which are inherent in the very nature of the sport. As a result of the aforementioned risks and hazards, I may suffer personal injury, property loss or even death as a result of my presence and actions at the facility of the L.U.C.Y. and RSEC and any activities I engage in with the L.U.C.Y. and RSEC or in or around the L.U.C.Y and Reaching Strides Equestrian Center facility. Some of the risks and hazards are foreseeable, but many others are not. I nevertheless, freely and voluntarily assume all possible risks and hazards and acknowledge that my use of the facilities at L.U.C.Y. and RSEC, while participating in any activities, shall be entirely at my own risk, or at the risk of those for whom I am a parent and/or guardian or caregiver. I understand that L.U.C.Y. and RSEC and its agents and employees and volunteers, do not assume any responsibility or liability whatsoever for my actions while I am engaged in any of the activities or using any of the facilities in any way. I have carefully read this Release, Waiver of Claim and Assumption of Risk, and declare that I understand it and that I am freely and voluntarily executing it. By signing this Release, Waiver of Claim and Assumption of Risk Warning, I will be FOREVER PRECLUDED FROM SUING OR OTHERWISE CLAIMING AGAINST L.U.C.Y. and RSEC its agents and employees and volunteers for any loss or damage or injury or death I may sustain as a result of my own actions. I understand that the L.U.C.Y. and RSEC will not permit me to use the facilities now or in the future at the Reaching Strides Equestrian Centre unless I sign this Release, Waiver of Claim and Assumption of Risk Warning. This Release, Waiver of Claim and Assumption of Risk are binding upon me, my heirs, my executors, administrators, personal representatives, assigns.

Signature of parent/legal guardian:*

Full name of participant:*

Full name of witness:*

Date signed:*

Date

Please verify that you are human*

L.U.C.Y

Participant

To be Completed by Adult and/or Parent Guardian

RELEASE, WAIVER OF CLAIM, AND ASSUMPTION OF RISK WARNING