Equine Assisted Activities Program Application

Equine Assisted Activities Program Application

Apply to participate in our equine-assisted activities program.
Participant Full Name

First NameLast Name
Date of Birth

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent /Caregiver or Emergency Contact Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Support Staff or Respite Worker Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please indicate any previous and current diagnoses:
Please describe any disabilities, medical conditions, allergies, or special needs we should be aware of.
What if any assistive devices does participant currently use (glasses, hearing aid, walker, wheelchair, leg/arm braces, smart device, etc)
Is participant comfortable around animals?
Briefly describe your goals or reasons for participating in the equine assisted activities program.
Signature
Consent Plan
NON-CONSENT PLAN I do not give my consent for emergency medical treatment/aid in the case of illness or injury during center activities or while on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedures to take place:
Non-Consent Plan
Photo Release
Signature
Should be Empty: