Horse-assisted Learning Packet

Welcome!

Pony Power connects people with disabilities or life challenges to the wonders of horses, farming and nature.

Participant Information

Participant's Name*

First Name

Last Name

Date of Birth*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Cell Phone*

Email*

Emergency Contact Information

Emergency Contact 1 Name*

First Name

Last Name

Cell Phone*

Relationship to Participant*

Emergency Contact 2 Name*

First Name

Last Name

Cell Phone*

Relationship to Participant*

Liability Release

would like to participate in the Pony Power Therapies, Inc. program. I acknowledge the risks and potential for risks of horsebackriding. However, I feel that the possible benefits to my self, my son, my daughter, my ward 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 Pony Power Therapies, Inc., its Board of directors, instructors, therapists, volunteers and/or employees for any and all injuries and/or losses I may sustain while participating in Pony Power Therapies, Inc.

Signature

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Use your mouse or finger to draw your signature above

Date

Photo Release

I consent to and authorize the use and reproduction by Pony Power Therapies of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.

I DO I do NOT

Welcome!

Participant Information

Emergency Contact Information

Liability Release

General Information

Photo Release