Student Application & Participation Packet

This replaces the paper Student Application and Participation forms. It indicates interest in a riding class — it doesn't guarantee a class spot. After submitting, you'll be taken straight to the Medical History form, which is also required before your first class.

Student information

Student's name

Address

City

ZIP

Phone (day)

Phone (evening)

Date of birth

Parent or guardian

Guardian name

Guardian phone

Student's profile

Height

Weight (lbs)

Sex

Disability (or none)

Does this rider use:

A cane

Leg braces

A walker

A wheelchair

Other aids

Range of motion limitations (hips/knees/ankles)

Anticipated problems sitting on the horse, or extra help/support needed?

Can this rider grasp reins?

Can this rider grasp a saddle horn?

Other hand holds

Can this rider walk up 3 steps to the mounting block?

Has this rider ever had seizures? If yes, extent/duration/frequency

Presently medicated?

Any breakthrough seizures?

Communication

Communication details (e.g. shy, over-active, deaf, hearing impaired, hugs a lot)

Specific fears, behavior issues, or other things we should know?

Why does the student want to participate in RideAbility?

Anything you'd like to share with our volunteers or donors? (optional)

Scheduling preferences

Class session — Spring, Summer #1, Summer #2, Fall

Day of the week

Time

Class/event & special needs

Class/event participating in

Description of any special needs

Description of any special training

Emergency contact & health insurance

RideAbility insurance does not include medical coverage for clients.

Who should we contact in an emergency?

Their phone number

Date of last tetanus shot

Health insurance provider

Policy number

If diagnosis is Down syndrome: date of last doctor's exam for Atlantoaxial Instability

Photo & publicity release

I consent to the use and reproduction of photographs, videos and other audiovisual materials taken of me (or my son/my daughter/my custodial child) for promotional material, educational activities, or any other use for the benefit or promotion of the RideAbility program or other equine-assisted activities and therapies.

I consent to the photo release, but I prefer to not have photographs taken when possible. I take responsibility for communicating my desire for no photographs or videos to staff, volunteers and guests. I do not intend to hold RideAbility liable for photographs or videos accidentally taken or taken by guests.

I do not consent to photographs or videos being taken of me (or my son/my daughter/my custodial child). I understand I must meet with the director to set up accommodations.

Signatures

Read each statement below, then type a full legal name once at the bottom to sign all of them.

Liability release to RideAbility

I, {name}, would like to participate in the RideAbility equine assisted activity program. I have been informed of the Minnesota Equine Liability Law, and I acknowledge the risks and potential for risks of horseback riding and working around horses. However, I feel that the possible benefits to myself (or my son/my daughter/my custodial child) are greater than the risk 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 RideAbility and its Board of Directors, Instructors, Therapists, Aides, Horse owners, Volunteers and/or Employees for any and all injuries and/or losses that I (or my son/my daughter/my custodial child) may sustain while participating in RideAbility affiliated classes, activities and special events of any kind.

Liability release to the property owners

I, {name}, do take full responsibility for myself and my family while on the property, Promised Meadows Farm. I agree to pay all medical expenses for myself and my family if I/we have any kind of accident while on this property. I will do all I can to keep myself and others safe from physical harm while on this property. 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 Jim and Jeanie Michelizzi for any and all injuries and/or losses that I (or my son/my daughter/my custodial child) may sustain while on the property owned by Jim and Jeanie Michelizzi, located at 10038 County Road 5 NW, Pine Island, MN.

Liability release regarding exposure to infectious disease

I, {name}, do take full responsibility for exposure to (and medical bills related to) infectious disease for myself, our family, our guests and our custodial children. We understand and acknowledge the risk of exposure to contagious and infectious diseases. However, I/We feel that the possible benefits to myself (or my son/my daughter/my custodial child) are greater than the risk 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 RideAbility and its Board of Directors, Instructors, Therapists, Aides, Horse owners, Volunteers and/or Employees for any and all diseases & contagions that I (or my son/my daughter/my custodial child) may be affected by while participating in RideAbility affiliated classes, activities and special events of any kind.

Minnesota Equine Liability Law acknowledgment

I, {name}, have read and/or been informed of the Minnesota Equine Liability Law (Minn. Stat. § 604A.12), which grants nonprofit organizations like RideAbility immunity from liability for injuries resulting from the inherent risks of livestock activities, with certain statutory exceptions.

I am the parent/legal guardian, signing on behalf of the student named above

Relationship to student (if signing as guardian)

Type your full legal name to sign all statements above By typing your name and submitting, you agree this counts as your signature, dated today.