Equine Therapy Liability Waiver

Equine Therapy Liability Waiver
Complete this form to register for equine therapy and acknowledge the liability waiver before participating.
Participant Information
Participant Full Name
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact and Safety Details
Emergency Contact Name
First NameLast Name
Relationship to Participant
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health and Safety Considerations
Equine Therapy Session Information
Preferred Session Date and Time
MonthDayYear
Date
Hour MinutesAM/PM Option
Preferred Therapy Type or Session Format
Prior Experience with Horses or Equine Therapy
Waiver Acknowledgment and Signature
Participant or Guardian Signature
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