Registration Forms 
 Therapy Clients form below the standard form.
This Form is for the  NON Therapy Clients 

Rider Name : 

Email and Cell Phone Number :  

Please submit this form with your Waiver.  You need you paper work to be done prior to or on your first Lesson arrival at Corner Stone Farm  

Medical Information   

Full Name:                                               Health Card #:                                       

Physician Name:                      Tel#:                       

Emergency Contact Name and phone number :                                   

 (other than above)     

Have you ever made an insurance claim in your past for personal injury? y/n

Please advise of any medical conditions,

ie. asthma, diabetes,  allergies, ADD, other. Do you carry and Epi- pen. Have you or your child received any psychological/psychiatric/family therapy in the last 12 months? 

Are you or your child currently taking any medication? Please note that all medications should be forwarded to the Riding Instructor  with full doctor's instructions. Under NO circumstances should a child carry his/her medication unsupervised. 
Do you/your child suffer from back problems? Yes /No (circle one)
Do you/ your child suffer from neck pain? Yes / No( circle one )
Are you/your child pregnant ? Yes /No (circle one) If you become pregnant at a later date I agree  that I will tell my instructor.

Are you currently on  disability?   Do you have any special needs issues?

Please give any details of any health problems that you may affect your riding. Please include a note with medical form.

Medical/Release Form The rider/camper and/or  his/her parent(s) and/or guardian(s) hereby acknowledge the risks and hazards inherent in riding and working around animals, not to be limited to: horses, chickens,  dogs various wildlife and cats and agree to assume all responsibility and risk of bodily injury or damage to property and further agree to hold harmless and indemnify Corner Stone Farm  and its owners, employees, volunteers, agents, and representatives from all claims for any bodily injury to persons or damage to property arising out of or resulting from the riding or  use of Corner Stone Farms’ premises or use of horses at or from Corner Stone Farm , as a rider, groom or spectator or otherwise in any type of Corner Stone Farms organize, sponsored, supported or endorsed activity, whether on Corner Stone Farm  premises or elsewhere, and including transportation provided Corner Stone Farm  or the individuals or organizers referred to herein. The student and his/her parent(s) and/or guardian(s) do hereby consent to any medical examination, treatment or medical services that may be rendered to said student under the general or specific instructions of any physician or hospital. It is understood that this consent is given in advance of any specific diagnosis or treatment. The camper and the undersigned parent(s) and/or guardian(s) agree to assume responsibility for payment of all fees for doctors, hospitals, ambulances and/or other medical charges reasonably and necessarily incurred. Insurance is the responsibility of the rider/camper and/or his/her parents. The student and his/her parent(s) and/or guardian(s) do hereby consent that photos/images of the student/rider may be used in Corner Stone Farm’s   articles and advertisements without payment or remuneration to that said camper/rider.

 I agree to inform Catherine Colwell , Joseph McAllister and/or  Corner Stone Farm if any of the above details change. I agree to abide by all the rules of Corner stone Farm while I am a client of the above establishment.  
If you have any questions about filling out the forms please contact Cathy.

  Cheque made out to Cathy Colwell
Should you need to withdraw you/your child from the lesson program, arrangements can be made to credit . All deposits are non-refundable.

50% of lesson cards are considered a deposit towards registration in the program.

Signature of rider:__________________________________

Print name: ______________________________________

Date and Signature :____________________________________ 

Parent or Guardian signature if client is a minor :____________________

 Please submit this form with your Waiver.  You need you paper work to be done prior to or on your first Lesson arrival at Corner Stone Farm  

This form for Therapy Clients 

1. The Client/Registration Form 

2. The Physician's Referral Form     

 Fill out and bring to first meeting/lesson

Physician's Referral Form:

Name of Client:___________________

Date of Birth: ____________________

Address:______________________________________________

Phone (home):___________(work):__________(cell):

Next of kin/Guardian:____________________________________

Living at home?:______________________Other:____________________

Medical:

Primary Diagnosis:_____________________________________________

Secondary Diagnosis:____________________________________

Height:_________Weight:_________Gender:_______

Diabetic?:_________Insulin?:______________

Epileptic?:______ Frequency of Seizures?:______Date of last seizure?:______

Medications:___________________________________________

Reason for medication:____________________________________________

Communicable disease: Yes_______No______If yes, explain:___________________________________

Surgery:____________________ attach details sheet if needed Date:_________________

Ambulatory: Yes_________No_________ If yes, explain:_______________________________________

Muscle Tone (spasticity, flaccidity, etc.):

Upper extremities:__________________________________

Lower extremities:__________________________________

Tone in trunk:_____________________________________

Balance sitting:________Standing:________Walking:______

Language (check): English:________French:_______Sign Language:______Other:__________________

Speech (check): Good:________Fair:________Poor:_____

Ability to understand (check): Good:_____________Fair:__________Poor:_________

Sensory Function(Good, Fair, Poor): Sight:___________ Hearing:____________Tactile:____________

Continence:_________

Allergies:yes or no if yes please include  add an attached sheet if needed

Physician's signature:______________________________Date:_____

Physician's name (please print):_________________________________

*details ie. height, weight, etc. will be used by program to best match rider with mount as well as to determine the proper amount of volunteers needed to best assist the rider

 Registration Form: Client:___________________________________________________

Date of Birth:________________Age:_______Height:_______Weight:_____

Address:______________________________________City:______

Province:________ Postal Code:__________Phone(home):____________(work):___________

Parent(s) or Guardian(s) if under 18:_________________________

Address(if different from above):____________________________

Province:_________Postal Code:__________Phone(home):____________(work):___________

Emergency Contact Name and Number:_________________________________________

Liability Release:

____________________________would like to participate in the K.A.R.A.T. program held at Corner Stone Farm, Kingston, ON.  I acknowledge the risks, and potential risks of horseback riding.  However, I feel that the possible benefits to myself/ my son/ my daughter/ my ward are greater than the risk assumed.  I hereby, intending to be legally bound, for myself, my heir and assigns, executors or administrators, waive and release forever, all claims for damages against K.A.R.A.T. and Corner Stone Farm, their Board of Directors, Instructors, Therapists, Aides, Volunteers, and/or Employees, for any and all injuries and/or losses that I/my son/ my daughter / my ward may sustain while participating in riding at Corner Stone Farm with the K.A.R.A.T. Program  

Date:__________________

Signature:_______________________

Witness:______________                                                                                                            (Client, parent, or guardian)

Photo Release:

I hereby consent to and authorize the use and reproduction by K.A.R.A.T of any and all photographs and/or any other audiovisual materials take of me/my son/my daughter/my ward, for promotional printed material, educational activities, exhibitions, or for any other use for the benefit of the program.

Date:____________Signature:_______________________                                                (Client, parent, or guardian)

Consent for Release of Information:

I hereby authorize ______________________________ (Person or facility)          to release information from the records of ___________________                                                                                (Client's Name)                                        The information is to be released to K.A.R.A.T. for the purpose of developing a therapeutic riding program for the above named client.  The information to be released is marked below:

                                  write in --  "YES", or " I agree " or  " NO" "declined"

________ Medical History

________ Physiotherapy evaluation, assessment, and/or program plan

_________ Occupational therapy evaluation, assessment, and/or program plan

_________ Speech therapy evaluation, assessment, and/or program plan

_________ Classroom Individual Education Plan (I.E.P)

_________ Other

Date:____________Signature:_____________________                                                                                    (Client, parent, or guardian)

Information Release:

I hereby authorize K.A.R.A.T. to release to its instructors and helpers such information as may be necessary to conduct a beneficial and safe riding program.

Name of rider: ___________________________________

Date:____________________

Signature:________________________                                                                                                                                                                                     (Client, parent, guardian)

Relation to rider if under 18: __________________________   

 Signature: ___________________________________

Witness  : _____________________________________

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