2026 Client Registration & Release / Health History Form Combined Client Registration & Release / Health History 0% Complete1 of 5 Client's First Name * Client's Last Name * Pronouns * He/himShe/herThey/themPrefer not to answer Date of Birth * Age * 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 Year started riding at Main Stay Parent/Spouse/Guardian Address if different from above Please provide Street, City, State and Zip Contact Information Please check if any information has changed so we can update our records * (Please Select)NoneYesNo Primary Email * Secondary Email Primary Phone * Secondary Phone Current Height * Current Weight * (Please be accurate as this affects our client weight limit requirements and the needs of our horses) Rider T-Shirt Size * Child - SmallChild - MediumChild - LargeChild - XLargeAdult - SmallAdult - MediumAdult - LargeAdult - XLargeAdult - XXLarge Diagnosis (Please list all relevant) * Medications (include dosage) is the client currently taking, including any over-the-counter medications? * Any hospitalizations and/or surgeries within the last year? * No YesYes If yes, please describe Medical History Allergies * No YesYes Behavioral * No YesYes Bone/Joint * No YesYes Breathing * No YesYes Circulation * No YesYes Communication * No YesYes Digestion * No YesYes Elimination * No YesYes Emotional/Psychological * No YesYes Hearing * No YesYes Heart * No YesYes Muscular * No YesYes Pain * No YesYes Sensation * No YesYes Thinking/Cognition * No YesYes Vision * No YesYes Other * No YesYes MOBILITY: (i.e. mobility skills such as walking, wheelchair use, transfers, driving/bus riding) FAMILY: (please share information on any siblings or other family members important to the client) 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) Consent I attest that this information is accurate (to the best of my knowledge). Main Stay Therapeutic Farm reserves the right to require an annual Medical History and Physician’s Statement from any client. I agree to release, indemnify and hold Main Stay (and its officers, directors and employees) harmless from any injury or loss arising out of any inaccurately reported or omitted medical information. Rider Name * (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~ Date Signed Signature * signature keyboard Clear If you are human, leave this field blank. Next EAAL Registration + ReleaseFacility Rental AgreementHorsemanship Registration + ReleaseRider Financial Assistance ApplicationRider Registration + ReleaseSaddle Up Registration + ReleaseSession PaymentWaiting List
