2022 Client Registration & Release / Health History Form Combined

Client Registration & Release / Health History
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Client Name
Client Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Please provide Street, City, State and Zip

Contact Information

(Please be accurate as this affects our client weight limit requirements and the needs of our horses)
Any hospitalizations and/or surgeries within the last year?
If yes, please describe

Medical History

Allergies
Behavioral
Bone/Joint
Breathing
Circulation
Communication
Digestion
Elimination
Emotional/Psychological
Hearing
Heart
Muscular
Pain
Sensation
Thinking/Cognition
Vision
Other

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) 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~