Roaring Acres Homeschool Horsemanship Program Registration

Roaring Acres

Homeschool Horsemanship Beginning Program Registration
Parent/Guardian Name

First NameLast Name
Student Information
Student Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Age of Student
Grade of Student
Gender
What is your student's experience with horses?
Emergency Contacts
Emergency Contact 1

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health Information
Are there any special considerations we should make for your student? (allergies, physical limitations, medical conditions, physical/behavioral limitations)
Does the rider have any history of seizures, fainting, or balance issues? If yes, please explain.
Authorization for Emergency Medical Treatment
Physician's Name

First NameLast Name
Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Medical Facility
Health Insurance Company
Policy #
Consent or Non-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 property of the agency, I authorize No Lemons Equine, Inc. to: Secure & retain medical treatment and transportation if needed and release client records upon request to the authorized individual or agency involved in the medical emergency treatment.

Consent Plan: This authorization includes x-rays, surgery, hospitalization, medication, and any treatment procedure deemed "lifesaving" by the physician. This provision will only be invoked if the emergency contact person(s) above is unable to be reached.

Non-Consent Plan: do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedure to take place:
Which Emergency Medical Treatment Plan do you authorize?
Release and Waiver of Liability
Photo Release: Please select below for consent to and authorize the use and reproduction by No Lemons Equine, Inc. of any and all photographs and any other audio visual materials taken on me for promotional material, educational activities, exhibitions, or for any other use for the benefit of the program.
Please read and fill out the Roaring Acres, LLC. Release and Waiver of Liability, Assumption of Risk, and Indemnity Agreement using the link below:

https://app.opensignlabs.com/login/NHh0MWdIQkJtNC9zZWVtYXllcmZhbWlseUBnbWFpbC5jb20vc0xvVEU3eXlGQi9mYWxzZQ==
Signature and Payment
Your signature below certifies that the information provided above is accurate. It is also an agreement that you will pay $225 per student to Roaring Acres. Your student will not be considered enrolled and a place will not be held for them until the full amount has been received.

Payment Options:
Venmo: @Heather-Conley-62
CashApp: $HeatherConley456
Arrange to bring payment directly to Heather Conley (text messaging is prefered): (352)812-7285‬
Parent/Guardian Signature
Should be Empty:

Roaring Acres

Student Information

Emergency Contacts

Health Information

Authorization for Emergency Medical Treatment

Release and Waiver of Liability

Signature and Payment