MAIN STAY THERAPEUTIC FARM      6919 KEYSTONE RD    RICHMOND IL, 60071    815.653.9374   CONTACT US

DONATE To encourage, enrich and empower individuals through the therapeutic benefits of horses, animals and nature in an uplifting and nurturing setting. Main Stay is a place where bodies are challenged, minds embrace possibilities, and spirits are renewed.

 

Client Registration and Release & Health History Form

Client Information

Please fill out all fields


Contact Information


FAMILY: (please share information on any siblings or other family members important to the client)

MOBILITY: (i.e. mobility skills such as walking, wheelchair use, transfers, driving/bus riding)


MEDICAL HISTORY

MEDICATIONS - (include dosage) is the client currently taking, including any over-the-counter medications?

SOCIAL: (i.e. work/school including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc)

GOALS: (i.e. what would the client like to accomplish)

(Rider) would like to participate in the Main Stay Therapeutic Farm, Inc. programs. I acknowledge the risks and the potential for risks of equine and animal interactions in a farm setting. However, I feel that the possible benefits to myself/my son/my daughter/my ward are greater than the risks 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 Main Stay Therapeutic Farm, Inc., its Board of Directors, instructors, therapists, aides, volunteers and/or employees for any and all injuries and/or losses I/my son/my daughter/ may sustain while participating in a Main Stay Therapeutic Farm, Inc. program. Under the Equine Activity Liability Act, each participant who engages in an equine or animal activity expressly assumes the risks of engaging in and legal responsibility for injury, loss, or damage to person or property resulting from the risk of equine activities. ~IL PWA-89-0111~

(if a minor)

Contact information

Main Stay Therapeutic Farm

6919 Keystone Rd., Richmond, IL 60071

Tel: 815.653.9374  Fax: 815.728.1224

Contact Us

info@mainstayfarm.org

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