2023 Equine Assisted Learning Registration Form

Participant Name*

Nickname

Birthdate*

Date

Age*

Gender*

Race/Ethnicity*

Street Address*

Street Address Line 2*

City*

State*

Postal / Zip Code*

Client Phone (or primary contact)*

Parent/Guardian 1 (For Minors)

First & Last Name*

Parent/Guardian 1 Primary Phone*

Parent/Guardian 1 Primary Email*

example@example.com

Parent/Guardian 1 Address (if different from above)

Address

Street Address Line 2

City

State

Postal / Zip Code

Parent/Guardian 2

Parent/Guardian 2 Primary Phone

Parent/Guardian 2 Primary Email

Emergency Contact*

Emergency Contact Primary Phone*

Emergency Contact Relation*

Client Medical History*

Client Psychological History*

Current Medications*

Please list any physical changes in the past year*

Please list any psychological changes in the past year*

Does the client participate in any therapies?*

YESNO

Any additional information or behaviors JoyRide staff should be aware of?*

What are the participants major goals at JoyRide Center?*

Billing Policy

Attendance: When you register for a semester, volunteers, horses and staff are assigned and look forward to working with you each week. If you are unable to make your class time, please give us at least 48 hours' notice. If you know of dates you will be absent, please notify the front office or email blake@joyridecenter.org. For last minute cancellations, call JoyRide's office at 281-356-5900. Clients will be charged regular tuition fee for cancelations or no shows. Three absences within one semester without notice may result in being dropped from the schedule.

How do you prefer to receive JRC Bills? (Check one)*

EmailedMailed

Billing Email

example@example.com

Billing Address

Responsible Party Signature*

Clear

Responsible Party Name*

Responsible Party Phone Number*

Waivers

Photo Release:

Consenting to this release helps JoyRide Center use photos to promote and fundraise our programs at events and on social media. This also helps prospective clients and parents get a better idea of what a day at JoyRide Center looks like!

To the use and reproduction by JoyRide Center of any and all photographs and any other audio/visual materials taken of me/my son/my daughter/myward/other family members for promotional printed material, educational activities, exhibitions or for any other use for the benefit of the program. JoyRide policy is that only first names will be used to identify people unless specific permission is given from the parent/client/guardian.

I hereby (check one)*

CONSENTDO NOT CONSENT

Printed Name of Parent/Guardian or Participant*

Date*

Date

Signature of Parent/Guardian Participant*

Clear

Liability Release

l/my son/my daughter/my ward would like to participate in the JoyRide Center, Inc. program. I acknowledge the risks and potential risks of horseback riding and working around or near farm animals. However, I feel that the possible benefits to myself/my son/my daughter/my ward are greater than the risk assumed. I hereby, intending to be legally bound, for myself, my heirs, and assigns, executors or administrators, waive and release forever all claims for damages against JoyRide Center, Inc., its Board of Directors, Instructors, Therapists, Aides, Horse Owners, Volunteers and/or Employees for any and all injuries and/or losses l/my son/my daughter/my ward/other family members may sustain while participating in JoyRide programs. WARNING- Under Texas Law (Chapter 87, Civil Practice and Remedies Code), a farm animal professional is not liable for an injury to or the death of a participant in farm animal activities resulting from the inherent risks of farm animal activities.

Printed Name of Parent/Guardian or Participant*

Date*

Date

Signature of Parent/Guardian or Participant*

Clear

CLIENT PACKET ACKNOWLEDGEMENT

I have read the client packet, and am aware of JoyRide Center's client policies. I acknowledge I am aware of the following polices: Tardy, Attendance, Billing,

Date*

Date

Signature*

Clear

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Privacy practices are found on the JoyRide Center website, joyridecenter.org/info-and-registration OR contact the office for a copy emailed to you.

Date*

Date

Signature*

Clear

Application Submission

Please complete all needed information and return to office manager, Blake Lewis, blake@joyridecenter.org.

Printed Name of Parent/Guardian or Participant*

Date*

Date

Signature of Parent/Guardian or Participant*

Clear

Client Registration Form