2024 Animal Assisted Learning Program Registration & Release Form AAL Registration and Release Client Name * First Last Age * Preferred Pronouns * School/Agency Attending (if applicable) Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone (home) * Phone (work) * Phone (mobile) * Parents or Guardian Contact in Case of Emergency * Emergency Phone * Health History Information Client's social/emotional behavioral goals by the end of the sessions * Client's diagnosis/disabilities * Client's Height * Client's Weight * Current Medications * Any other medical concerns/issues * Able to navigate uneven surfaces? Yes If No, please describeIf No, please describe Please indicate if the client has a history of the following: Seizures * No If Yes, please describeIf Yes, please describe Allergies * No If Yes, please describeIf Yes, please describe Bees * No If Yes, please describeIf Yes, please describe Animals * No If Yes, please describeIf Yes, please describe Dust * No If Yes, please describeIf Yes, please describe Asthma * No If Yes, please describeIf Yes, please describe Liability Release Consent Date * Signature * signature keyboard Clear Parent or Guardian Photo Release Client Name * Yes or No I Do I Do Not hereby grant irrevocable and unlimited consent to the use and reproduction by Main Stay Therapeutic Farm, its assigns, licensees and legal representatives, of any and all photographs and any other audio/visual materials taken of me, my child or my ward, in all forms and media (including but not limited to printed media, digital media, web sites, video and audio productions). The materials may be reproduced in all forms including composite, altered or derivative works, for promotional material, educational activities, and exhibitions or for any other lawful use for the benefit of the program. I hereby waive the right to inspect and approve the finished version(s) including any copy that may accompany the materials. I hereby release Main Stay and its employees, volunteers, assigns, licensees and legal representatives from all claims and liability relating to said materials. I sign this release as a person with, or the parent or guardian of a person with special needs, understanding that use of these materials will make them available to the general public. I am the parent or guardian of the minor child, or dependent adult named above and have the legal authority to execute the above release. I approve the foregoing and waive any rights in the premises. Please Select * I am over 18, I have read and understand the above release, and have the capacity to sign this release of my own free will. (18 years and older) I am the parent or guardian of the minor child or dependent adult named above and have the legal authority to execute the above release. I approve the foregoing and waive any rights in the premises. Client, or Parent/Guardian Signature * signature keyboard Clear Date Signed * reCAPTCHA If you are human, leave this field blank. Submit Rider Registration FormSession PaymentRider Financial Assistance ApplicationSaddle Up Registration and Release
