New Participant Application

New Participant Application

Please fill out this form if you are interested in lessons. Someone will reach out to you soon.
Group Prefill
Please select the Session you are applying for:*
Student Name*

First NameLast Name
Address*

Home Address

Street Address Line 2

CityState

Zip
Phone*
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Height*
Required for equine pairing.
Weight*
Required for equine pairing.
Gender*
Pronouns*

Demographic Information
Demographic Information Collection Notice: Thank you for your interest and participation in our event/program. As part of our commitment to transparency and inclusivity, we are collecting demographic information from registrants. While this information is optional to provide, we want to inform you about the importance of this data collection for the following reasons:

(1) Legal and Funding Compliance: To meet legal and funding requirements, we are obligated to report demographic information to government and funding entities. This data helps ensure accountability, measure the impact of our programs, and demonstrate compliance with diversity and inclusion standards.

(2) Inclusive Program Design: Understanding the diverse backgrounds of our participants allows us to design programs and events that better meet the needs and preferences of our community. Your demographic information helps us tailor our offerings to be more inclusive and accessible.

(3) Equality and Diversity Advocacy: By voluntarily providing demographic information, you contribute to the promotion of equality and diversity within our organization and the broader community. This information supports our efforts to create a more inclusive environment.

(4) No Impact on Participation: We want to emphasize that providing demographic information is entirely optional, and your decision to do so will not affect your eligibility or participation in our event/program. Your privacy and confidentiality are of utmost importance to us.How to Provide Demographic Information: If you choose to share your demographic information, you can do so during the registration process by selecting the relevant options. Alternatively, you can opt not to provide this information, and it will not impact your registration.We appreciate your understanding and cooperation in helping us gather this valuable information. If you have any questions or concerns, please feel free to reach out to our team.
Ethnicity*
Race*
Employment Status*

Employed Full TimeEmployed Part TimeStudentRetiredUnemployedNot Employed/Not LookingI decline to answer
Employer/School
Household Income Level*
Veteran Status*

Participant's Medical History
Physicians Name*
Physician's Phone*
Preferred Medical Facility*
Allergies to Medications*
Type "none" if no allergies.
Current Medications*
Type "none" if no current medications.
Special Precautions, Diets, Needs, and/or other Allergies*
Type "none" if no current medications.
Applicant may participate in all activities:*

Yes, no activity restrictionsNo, applicant has activity restriction(s)
If Applicant has activity restrictions, please list below:
Mobility Classification*

Independent AmbulationAssisted AmbulationWheelchair

Parent/Guardian/Caregiver Information

If applicable
Primary Parent/Guardian/Caregiver Name

First NameLast Name
Primary Parent/Guardian/Caregiver Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Primary Parent/Guardian/Caregiver Phone Number
Primary Parent/Guardian/Caregiver Email
example@example.com

Emergency Contact Information

At least one required
Emergency Contact #1 Name*

First NameLast Name
Emergency Contact #1 Relation*
Emergency Contact #1 Phone*
Emergency Contact #2 Name

First NameLast Name
Emergency Contact #2 Relation
Emergency Contact #2 Phone

Consent & Release Provisions

Please read and initial each section, below.
Emergency Medical Treatment & Consent Plan:

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize Strongwater Farm to:

1. Secure and retain medical treatment and transportation if needed.

2. Release my records upon request to the provider of any such medical emergency treatment. This authorization includes, without limitation, x-ray, surgery, hospitalization, medication and any treatment procedure deemed by a physician to be an appropriate means to attempt to save the Participant's life. This provision will be invoked only if Strongwater Farm is unable to reach the person(s) named above.
Consent*
In the event of an emergency where first aid/treatment is required while Applicant is engaged in Strongwater activities, I wish the following procedure(s) to take place:
Parent/Guardian/Caregiver will remain on-site at all times during equine-assisted activities (if applicable)

YesNo
Photo Release:

I consent to and authorize the use and reproduction by Strongwater Farm of any and all photographs and any other audio/visual materials taken for promotional materials, educational activities, exhibitions or for any other use Strongwater Farm deems to be of benefit to its program.
Photo Release Consent*

I agree with the above Photo ReleaseI do not wish for my photo or other audio/visual materials to be used
Confidentiality Agreement:

I understand that all information, written and verbal, about Applicants in Strongwater Farm’s lessons and programs and volunteers and personnel of Strongwater Farm is strictly confidential and I agree not to share it with anyone without the express written consent of such Applicant, volunteer or personnel and his/her parent/guardian/caregiver in the case of a minor.
Confidentiality Agreement*

I agree with the above Confidentiality AgreementI do not agree with the above Confidentiality Agreement
Under Massachusetts law, an equine professional is not liable for an injury to, or the death of, a participant in equine activities resulting from the inherent risks of equine activities, pursuant to section 2D of chapter 128 of the General Laws. Participant would like to participate in equine activities at Strongwater Farm Therapeutic Equestrian Center, Inc. ("Strongwater Farm" I (or the Participant's Parent(s)/Guardian(s acknowledge and understand that horses and activities related to horses are inherently dangerous and that there are dangers and risks which are an integral part of equine activities, the Participant or the Participant's Parent(s)/Guardian(s) acknowledge the risks and potential for risks of equestrian activities. Despite these inherent risks, the Participant (or the Participant's Parent(s)/Guardian(s feels that the possible benefits to himself/herself/his or her son/daughter/ward are greater than the risks assumed, and the Participant (and the Participant's Parent(s)/Guardian(s has chosen to participate in Strongwater Farm's equestrian program (the "Activities") (and the Participant's Parent(s)/Guardian(s) have agreed to allow the Participant to engage in the Activities The Participant (and the Participant would like to participate in equine activities at Strongwater Farm Therapeutic Equestrian Center, Inc. ("Strongwater Farm" I (or the Participant's Parent(s)/Guardian(s Participant's Parent(s)/Guardian(s agree that he or she shall not hold Strongwater Farm Therapeutic Equestrian Center, Inc. liable for injury to or death of the Participant (or the Participant's Parent (s)/Guardian(s resulting from or related to his or her involvement in equine activities and/or the Activities. The Participant(and the Participant's Parent(s)/Guardian(s intending to be legally bound hereby remise, release and forever discharge Strongwater Farm Therapeutic Equestrian Center, Inc. its officers, directors, employees, independent contractors, assigns, members, insurers, instructors, therapists, aides, participants, agents, representatives and any others acting on Strongwater Farm's benefit, for him or herself and his or her heirs, executors and administrators, of and from all manner of actions, cause or causes of actions, suits, reckonings, controversies, damages, claims and demands, in law or at equity, that he or she now has or hereafter can or may have or which his or her heirs, executors or administrators hereafter can, shall or may have by reason of any injury to or death of the Participant (or the Participant's Parent(s)/Guardian(s caused by or in any manner related to equine activities and/or the Activities or while participating in Strongwater Farm's equestrian program. Moreover, I understand that Strongwater Farm is an equine activity sponsor, as M.G.L. ch 128, section 2D defines that term and that Strongwater Farm Therapeutic Equestrian Center, Inc. shall not be liable for any injury or death that results from the inherent risks of equine activities, and I shall not make any claim on my own or the Participant's behalf against Strongwater Farm Equestrian Center, Inc. The Participant (and Participant's Parent(s)/Guardian(s hereby acknowledges that he or she has been warned about the risks related to equine activities and the Activities. The Participant (and the Participant's Parent(s)/Guardian(s has had the opportunity to ask questions of Strongwater Farm and is satisfied that he or she understands the risks involved in equine activities and the Activities. By his or her execution of this Release Form, the Participant (and the Participant's Parent(s)/Guardian(s agrees to be bound by and comply with the terms hereof and acknowledges that he or she wishes to engage in equine activities despite the risks and potential dangers involved. The Participant (and the Participant's Parent(s)/Guardian(s has not relied on any representations, statements or warranties of Strongwater Farm other than those specifically set forth herein.

Consent Signature: Applicant (or Parent, Legal Guardian or Caregiver, if under 18 years)

(Scroll to bottom of text box before checking the box.)
Date

MonthDayYear
Date
Consent Signature

Clear
Describe Participant's abilities/difficulties in the following areas (include assistance required or equipment needed):
Physical Function (i.e. mobility skills such as transfer, walking, wheelchair use driving, bus riding, etc.)
This information helps us place participants.
PsychoSocial Function (i.e. work/school [including grade completed], leisure interests, relationships/family structure, support systems, companion animals, fears/concerns, etc.)
This information helps us place participants.
Goals (i.e. why is Participant applying for participation, what would Participant like to accomplish)
This information helps us place participants.
Date

MonthDayYear
Date
Participant (or Parent/Legal Guardian/Caregiver, if under 18 years of age)

Clear
SFPrimaryContact

First NameLast Name
Should be Empty:

New Participant Application

Demographic Information

Participant's Medical History

Parent/Guardian/Caregiver Information

Emergency Contact Information

Consent & Release Provisions