KARAT Therapy Riding at Corner Stone Farm

Registration Forms

Required Screening Questions

IF you click the links above its a better format for printing if not please fill in and send back to me – email is fine

circle answers and add details to bottom

		Mandatory COVID-19 Screening
Please fill out this quick survey prior to your visit to help everyone stay safe and healthy!
		1. Do you have a fever?
		Yes	NO
		2. Do you have any of the following signs or symptoms?
		New onset of cough			Difficulty breathing
		New loss or decrease in sense of taste or smell
		Runny nose			Worsening chronic cough
		Sneezing (not allergy related)			Sore throat
		Hoarse voice			Shortness of breath
		Headache			Nasal congestion
		Unexplained fatigue or malaise			Chills
		Difficulty swallowing			Pink eye
		Nausea/vomiting, diarrhea, abdominal pain

		3. Have you travelled or have had close contact with anyone who
		has travelled outside of Canada in the past 14 days?
		Yes	NO
		4. Have you had close contact with anyone with respiratory
		illness or a confirmed or probable/suspected case of COVID-19?
		Yes	NO
		5. Have you visited, resided in or had guests from a location in red or lockdown (grey) status or from outside Ontario?

		Yes	NO
		6. Has your work place been closed in the last 14 days ?
		Yes	NO

initial		If you have answered "yes" to questions 1, 3, or have checked off signs or symptoms,
_______		you may need to reschedule your appointment.
initial		If you have answered "yes" to question 4 but "yes" to question 5, you may proceed with your appointment.
	Yes	I declare that I have answered the above questions fully and honestly
	Yes	I declare that I understand that I am to contact Cathy immediately if I answered yes to any questions
	Yes	or my answers change within 10 days of being on the farm
	Yes	or in contact with Cathy or any of the staff at Corner Stone Farm
		signature :		Date:

below are forms for therapy riders - for all other lessons please click above for the waiver and other forms

CORNER STONE FARM

Waiver to Print - Fill in completely and initial all spaces.

ACKNOWLEDGMENT of RISK and RELEASE of LIABILITY WAIVER for those under 18 years old

Participant’s Name:
Date of Birth:
if under 18 Guardian’s Name:
Participant /or Guardian’s Address:
Phone Number:
E-mail:
Full Address:
City:

HOST : Catherine Colwell and Joseph McAllister, Corner Stone Farm,(Name of Person, Organization or Company providing the Equine Activities) volunteers, business operators, and site property owners. (all of them collectively called the HOST).corner stone farm, KARAT riding, their directors, employees, officers.
The Participant and Guardian must Read and Understand prior to the Participant
Participating in Equine Activities

Initial each item below After Reading and Understanding the item

__1. I am the Parent and/or Legal Guardian of the infant Participant named
above and am executing this form on behalf of the infant Participant in my
capacity as parent and/or guardian and with the intent that this form be binding
on myself and infant Participant for all legal purposes.
_2. 1 Understand there are Inherent DANGERS, HAZARDS and RISKS,
(collectively called RISKS) associated with Equine Activities and injuries resulting
from these “RISKS” are a common occurrence.
_3. I Acknowledge that the Inherent “RISKS” of Equine Activities mean those DANGEROUS conditions which are an integral part of Equine Activities, including but not limited to: which are an integral part of Equine Activities, including but not limited to:
• The propensity of any equine to behave in ways that might result in
injury, harm or death to persons on or around them and to potentially collide with,
bite or kick other animals, people, or objects.
• The unpredictability of an equine’s reaction to such things as sounds,
sudden movement, tremors, vibrations. unfamiliar objects, persons or other
animals and hazards such as subsurface objects.
• The potential for other participant (s) to act in a negligent manner that
might contribute to injury to themselves or others, such as failing to act within
their ability or to maintain control over an equine.
_4. I Freely Accept and Fully Assume All Responsibility for the Inherent “RISKS” and the possibility of personal injury, death, property damage or loss
which might result from the infant being a Participant.
_5. 1 Acknowledge that it remains my Sole Responsibility for the safety of the infant Participant and for the infant to Participate within his/her own limits.
_ 6. I understand that I could become infected with COVID-19 while at the facility.
_ 7. I agree to waive all liability and to indemnify the facility for damages
that may be incurred by the facility result of any mis-statement in this self declaration.
8. I understand the risks of coming into contact with other people during the COVID-19
global pandemic facility.
9.To your knowledge have you or anyone in your household had contact of any kind
with someone diagnosed COVID-19 (presumptively or confirmed) within the last 15 days?
yes or no ? Explain ___
10.Have you or anyone in your household experienced any cold or flu-like symptoms in the last 15 days,including, but not limited to fever, fatigue ,cough, sore throat, loss of taste or smell, respiratory illness, shortness of breath or difficulty breathing? yes or no ?
Explain _
10 B). I understand that I am to immediately contact Cathy if you have any exposure to a positive case. ( circle) yes and initial _
11. Have you or anyone in your household returned from any destination outside of Canada or travelled airplane from any destination within the last 15 days? yes or no ? Explain
12. I understand that should circumstances arise I have a duty to the facility to refrain from entering the until a period of 15 days has passed. yes or no
13. Any person visiting the farm, is required to enter/exit the facility gate and are to use hand sanitizer before and after opening or closing gate in warm weather the soapy wash cloth provided on the gate.
___14. In addition to consideration given for the infant to Participate in Equine Activity, I and my heirs, executors, administrators and assigns (collectively called
my “Legal Representatives”) agree
• To Waive All Claims that I or the infant Participant might have against the “HOST”; and
• To Release the “HOST” from Any and All Liability for any loss, damages, injury, or expense that I. the infant Participant or our “Legal Representatives” might suffer as a result of the infant’s Participation due to any cause including any NEGLIGENCE ON THE PART OF THE “HOST”: and
• To HOLD HARMLESS AND INDEMNIFY THE “HOST” from any and all liability for property damage or personal injury to the infant Participant or to any third party which might result from the infant’s Participation.
Before signing this form I read it (as indicated by my initials above) and I stated that I understand it. I further state I am aware that signing this form, waives certain legal rights I and/or the infant Participant and/or our “Legal Representatives” might have against the “HOST”.

SIGNED This ______________ day of____________________________.

Corner Stone Farm / Catherine Colwell and Joseph McAllister

(Name of HOST ) Catherine Colwell (Signature of Participant) Do Not Sign until you Understand All Items AboveWitness to signing & Initialing) _________________________________

(Signature Host Witness)

Therapy Client 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 : ___________________

Corner Stone Farm

Links to printable waivers and forms Click on these

Participant’s Name:
Date of Birth:
if under 18 Guardian’s Name:
Participant /or Guardian’s Address:
Phone Number:
E-mail:
Full Address:
City:

Corner Stone Farm

Covid-updates

Lesson Types and Pricing

Waivers and forms

Therapy Riding ( KARAT)

Fund Raising for RIDERS

Photo Gallery

Contact US

Links to printable waivers and forms Click on these

Participant’s Name: Date of Birth: if under 18 Guardian’s Name: Participant /or Guardian’s Address: Phone Number: E-mail: Full Address:City:

Participant’s Name:
Date of Birth:
if under 18 Guardian’s Name:
Participant /or Guardian’s Address:
Phone Number:
E-mail:
Full Address:
City: