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Participants Name

First Name

Last Name

Guardian/Participant Legal Signature - (By typing your name, you are authorizing this as your legal digital signature)

First Name

Last Name

Phone

(###)

###

####

Emergency Contacts are required for clients and volunteers in case of an emergency. Two Emergency Contacts are required and the 3rd is helpful if the first two do not answer the phone. Yes, you have my permission to call emergency services if there is an emergency. This will be an option if the caregiver or guardian is not listed above and is not available through a phone call.

Guardian/Participant Legal Signature - (By typing your name, you are authorizing this as your legal digital signature)

First Name

Last Name

Date / Time of Signature

YYYY

Diabetes Alert

Type in any diabetes alerts or just type N/A

Insurance Name/ #ID

Optional

Allergies

Type in any allergies the participant has or just type N/A

Please Choose One:

Preferred Hospital

Nearest Hospital

Date Of Birth

YYYY

Primary Doctor and Phone #

Highly recommended for emergencies but Optional

Emergency Contacts are Required per Professional Association Therapeutic Horsemanship (PATH)

EMERGENCY CONTACT #1

Friend/Relative

Name

Phone Number

Home Phone

Address

EMERGENCY CONTACT #2

Friend/Relative

Name

Phone Number

Home Phone

Address

EMERGENCY CONTACT #3

Friend/Relative

highly recommended, but optional Friend, Cousin, or grandparent

Name

optional

Phone Number

optional

Home Phone

optional

Address

optional

All information will remain confidential and filed. This information is only used if necessary for an emergency. Majestic I: 7460 Wooster Pike Road, Seville, Ohio 44273. Majestic II: 7859 Westfield Road, Medina, OH 44256

Services: Confidentiality must be maintained for all private information, including medical history, details related to insurance. Information will be shared strictly on a need-to-know basis to ensure that volunteers can assist effectively and safely.

Check all that applies

Therapeutic Riding Application

Participation Requirements: Safety First: This principle is essential. Includes closed toe shoes to prevent foot injuries.

• Includes closed toe shoes to prevent foot injuries. • Appropriate clothes attire: No midriffs shown wearing tank-tops and t-shirts. Wear long pants or suitable shorts that are not excessively short. No use of offensive language on shirts. • Any injury from horse or from being on the property, please notify Instructor/Director. • Please contact Jennifer below if you cannot find the location. 440-668-8364

Participant Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Of Birth

YYYY

Age

Height

(By Medical Professional on Physical)

Weight

(By Medical Professional on Physical)

Gender

Male

Female

Other

Cell Phone

(###)

###

####

Home Phone

(###)

###

####

School Name

Students Only

Home Schooling

Students Only

Yes

IEP

Students Only

Yes

ISP

ADULTS ONLY

Yes

Group Home

ADULTS ONLY

School/Group Home/Or Other Referral

(if applies)

Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

School/Group Home/Or Other Referral 2

(if applies)

Name 2

Address 2

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone 2

(###)

###

####

Email 2

Cell Phone 2

(###)

###

####

Youths Only 6 to 17 years old

CAUTION: READ CAREFULLY BEFORE SIGNING. ONE SIGNED COPY REQUIRED FOR EACH INDIVIDUAL WHO PARTICIPATES IN AN ACTIVITY. Equine Liability | Majestic Equine Connections, Inc. I agree to the following Waiver, Agreement, and Liability Release with Majestic Equine Connections, Inc. and/or affiliated persons associated with the equine activities (referred to herein as "The Property Owners ("Danny & Jennifer Stankiewicz"), as a condition for its allowing me, and the other persons identified below, to do any of the following: enter any premises or facility where equine activities are conducted, be near horses in connection with any equine activities (handling, grooming, near, or riding horses). Agreement regardless of whether these activities take place under the supervision of "The Property Owner and Lessee" and its affiliates Majestic Equine Connections, Inc..at the following addresses: 7460 Wooster Pike Rd. Seville, Ohio 44273 and 7859 Westfield Road Medina, Ohio 44256.

CONTRACTING PERSON(S) Write Clearly

Participants's Name

First Name

Last Name

Date Of Birth

YYYY

Participant Legal Signature - (By typing your name, you are authorizing this as your legal digital signature)

First Name

Last Name

Date Of Signature

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Legal Signature - (By typing your name, you are authorizing this as your legal digital signature)

First Name

Last Name

Date of Signature

YYYY

Additional Participants with same Guardian/Parent adding on: I also make this agreement of behalf of the following, who are my children or legal wards:

Name

First Name

Last Name

Date of Birth

YYYY

Name

First Name

Last Name

Date of Birth

YYYY

Name

First Name

Last Name

Date of Birth

YYYY

All parts of the Waiver, Agreement, and Liability Release shall apply to me, and the children/legal wards listed above. (We will collectively call ourselves "I", "me", or "my", throughout this agreement.) This Waiver, Agreement, and Liability Release will be binding at all times, now and in the future, even after my relationship with "The property Owner" (Majestic Equine Connections, Inc.)

RELEASE STATEMENT I understand that parts of the activities may be physically or emotionally demanding. I affirm that I (or the participant) am in good health and am not under a physician's care for any undisclosed condition that bears upon my (or their) ability to participate in this activity. I understand that "The property Owner" will offer safety equipment such as helmets and I affirm I will wear proper closed toe shoes. I recognize the inherent risk or injury or disability and understand that each participant must assume the risk of physical injury that could result. I release "The property owners" (Majestic Equine Connections, Inc.) volunteers, and board members from liabilities resulting from participating in these activities. This release is governed by the State of Ohio.

WARNING Under the Ohio Equine Activity Liability Act, (Ohio Revised Code Chapter 2305.321) an equine professional is not liable for an injury or the death of a participant in an equine activity resulting from an inherent risk of equine activity. It is mutually understood and agreed that the liability release set forth herein shall constitute a waiver of liability beyond the provisions of the Ohio equine activity liability act. By signing this agreement and liability release, I agree not to bring any claim or suit against "The property owner" or volunteers, affiliated persons, and others acting on their behalf on the basis of any exception in that law. It is my intention to release and hold harmless "The property owner" or persons affiliated and entities associated with "The property owner" to the fullest extent allowed under the law. HELMETS/HEADGEAR I agree to be fully responsible for my own safety at all times. "The property owner" has suggested that I buy and wear a properly fitted ASTM-STANDARD/SEI-CERTIFIED EQUESTRIAN helmet when riding or near equines. I am not relying on "The property Owner" to provide a certified helmet for me, to check any helmet or strap that I may wear, or to monitor my compliance with this suggestion at any time. LIABILITY RELEASE: As consideration for being to enter on property, to be near equines in connection with any "The property owner/lessee" activities (regardless of who owns the equines), and/or engage in any other activity involving horses/equines, whether or not under "The property owner" supervision, I agree to assume full responsibility for any and all bodily injuries or damages which I may sustain when engaging in these and other activities. The term "damages," means, for example, medical expenses, losses incurred I because of bodily injuries or property damages, and/or personal property damages. I, for my heirs, administrators, personal representatives or assigns, release and discharge "The property owner" and its affiliated persons, and others acting on their behalf of and from any and all claims, demands, damages, actions, omissions, suits, or causes and action (present and future), whether the same by known or unknown, anticipated omissions, suits, or causes of action (present or future), whether the same by known or unknown, anticipated or unanticipated, resulting from or arising out of my bodily injury or damage that may be sustained, or property damage which may occur as a result of being on the property, handling horses, being near horses, and/or engaging in any other activity involving horses, whether or not under "The property owner" supervision. It is my intention to RELEASE/WAIVER OR HOLD HARMLESS Danny & Jennifer Stankiewicz (Majestic Equine Connections, Inc.) ("The property Owner" and Lessee) or persons AFFILIATED with equine activities and/or other animals at the following addresses:

7460 Wooster Pike Rd. Seville, Ohio 44273. Other: Trail Rides on Program Horses (Off-Site)

7859 Westfield Road Medina, Ohio 44256 Other: Parades, horse shows, or off-site activities

EQUINE-RELATED RISKS: I understand that anyone riding, handling, or even near a horse (referred to as "equine") can suffer bodily and other injuries. Among other things, equines are unpredictable by nature. For example, frightened, angry, or under stress, the natural instincts of an equine are to jump forward or sideways or run away from danger by trotting or galloping. Equines are also known to kick, buck, rear up, back up quickly, spin around, strike, or bite. I know that equines can do any of these things without warning. I also understand that all equines, even if they have no known history of hurting people or animals, are powerful and can be dangerous to people, and other animals.

I fully read and agree with the above. (Proper footwear is required - Closed-Toe shoes or boots)

Participant Name

First Name

Last Name

Signature/Or Guardian (By typing your name, you are authorizing this as your legal digital signature)

First Name

Last Name

Date

YYYY

Under Ohio law (Ohio Revised Code Section 2305.321), horse owners and other parties are protected against liability for injuries that occur as a consequence of an inherent risk of equine activity

HEALTH HISTORY

Client/parent/guardian can fill out without a physician.

Diagnosis: Date of Onset: Please indicate current or past special needs in the following areas: Check box & explain if applies.

Surgeries in the past 5 years

(If none type N/A)

Pertains to Down Syndrome Only - Atlantoaxial Instability (Annual X ray Required) Only 10%-20% persons with Down Syndrome have positive cases. Typically, no signs of instability.

Negative for neurological symptoms

Negative X-ray

Mastering your Skills! Check your lists! Therapeutic Horseback/Horse Lessons Main focus: Mastering Horseback Riding Skills Horse Connections Program

Main Focus: Mastering Horse Skills/Bonding with horses or animals

Riding Skills - Western

Please check all that apply

Trail Riding

Obstacles

Walk/Trot

Independent riding without a horse leader

Intermediate | Cantering (must be able to hand riding in different patterns and in control)

Riding Skills - English Forward Seat

Please check all that apply

Hunt

Two Point Over Poles

Trail Riding

Walk\Trot

Independent riding without a horse leader.

Intermediate | Cantering (must be able to hand riding in dfferent patterns and in control)

Other

Application Fee - Please indicate whether or not your application fee will be covered by County Resources.

The $30 application fee will be covered by me

I have an arrangement in place for the $30 application fee to be covered by county resources

COST OF SERVICES

Choose between Group or Private Sessions

Group Sessions - 45 min to 1 hour - (Adaptive/Typical) - 9 weeks x $40 - $360

Private Sessions - 30 min to 40 min - (Adaptive/Typical) - 9 weeks x $50 - $450

Choose between Session Dates

Your classes will take place during one of these session ranges

Session 2 - Start Week - Mon. March 17th - End Week Sat., May 17th

Session 3 - Start Week - Mon. June 2nd - End Week Sat., August 2nd

Session 4 - Start Week - Mon. August 11th - End Week Sat., October 11th

Session 5 - Start Week - Mon. October 20th - End Week Sat., December 20th

Please check that you completed all sections and submit. After submitting your must complete payment and scheduling to finish the process.

Therapeutic Riding Application Form

Majestic Equine Connections, Inc.

Majestic Equine Connections, Inc., 501 (c)(3) 7460 Wooster Pike Rd. Seville, Ohio 44273 (440) 668-8364