2023 Saddle Up Registration + Release Saddle Up Registration & Release Name * First Last Date of Birth * Age * Preferred Pronouns * 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 Email * Phone * In case of emergency contact * Current Height * Current Weight * Medications (Include dosage and any over-the-counter medications) * Mobility (any issues or concerns) * Please indicate current or past problems in the following areas Allergies/Asthma * No YesYes Bone/Joint * No YesYes Breathing * No YesYes Circulation * No YesYes Communication * No YesYes Digestion/Elimination * 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 Please describe your previous riding experience including level of experience, how long ago and type of riding done * What would you like to accomplish? Is there any other information that will enhance your time at the farm? * LIABILITY RELEASE Consent Signature * Clear Client (18 years or older), Parent or Guardian Date Signed * PHOTO RELEASE Client's Name * I, Client's name Give Consent * DO 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 have read and understand the above release, am over 18 and have the capacity to sign this release of my own free will. (18 years and older) Client/Parent Signature * Clear Date Signed * reCAPTCHA If you are human, leave this field blank. Submit 2023 Rider Registration Form2023 Session Payment2023 Rider Financial Assistance Application2023 Saddle Up Registration and Release
