Begin Registration

1Start

2Participant Info

3Health History

4Emergency Info

5Review

6Consents

This field is for validation purposes and should be left unchanged.

Registration Type(Required)

New Participant

Returning Participant

Date of Last Participation (returning participants only)

MM slash DD slash YYYY

Who is completing this registration form?(Required)

Self (I am the participant)

Parent/Guardian

Is the participant 18 or older?(Required)

Yes

Does the participant have a legal guardian?(Required)

Yes

Are you registering as part of a group?(Required)

Yes

Name of Group/Organization

Participant Information

Please complete the below information for the participant as thoroughly and accurately as possible.

Participant Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Gender

Female

Male

Non-Binary

Race (optional)

Sometimes, this information is requested when we apply for grants.

Employer or School

Participant Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Email is our primary method of communication. If you do not have an email address, please contact our office at 317-773-7433 for assistance.

Parent/Adult/Guardian Information

If the participant is under the age of eighteen (18) or under legal disability, the parent/adult/guardian must complete this section.

Contact Name

First Last

Relationship to Participant

Contact Phone

Contact Email

Emergency Contact

Check the box if the Primary Contact is an emergency contact for the participant

Contact Mailing Address

Same as Participant

Street Address City State ZIP Code

Employer

Work Phone

Secondary Contact Name

First Last

Relationship to Participant

Secondary Contact Phone

Secondary Contact Email

Emergency Contact

Check the box if the Primary Contact is an emergency contact for the participant

Secondary Contact Mailing Address

Same as Participant

Street Address City State ZIP Code

Caregivers/Drivers

Please list any other caregivers not listed above who may transport or be responsible for the participant.

Contact Name

First Last

Relationship to Participant

Emergency Contact

Check the box if this person is an emergency contact for the participant

Household

This person lives in the same household as the participant.

Contact Name

First Last

Relationship to Participant

Emergency Contact

Check the box if this person is an emergency contact for the participant

Household

This person lives in the same household as the participant.

Participant Medical History

All participant information is maintained as confidential and accessed only by authorized personnel as necessary to ensure safe and appropriate services.

Primary Diagnosis/Disability(Required)

Date of Onset (if applicable)

MM slash DD slash YYYY

Other Diagnosis/Disability

Seizures(Required)

Yes

Seizure Type

Controlled

Yes

Date of last seizure

MM slash DD slash YYYY

Health & Safety Screening

For the safety of participants and equine partners, a Physician Release will be required if any of the items below are checked.

Height (in)(Required)

Required to ensure safe and appropriate equine pairing.

Weight (lbs)(Required)

Agape maintains a 200-pound maximum rider weight limit. Required to ensure safe and appropriate equine pairing

If the participant has any of the following, check the cooresponding box.(Required)

Crutches

Walker

Braces

Wheelchair

G-tube

Catheter

Shunt

N/A

Has the participant ever been treated for any of the following?(Required)

Down Syndrome

Spinal condition (i.e. injury, scoliosis, fusion, Spina Bifida)

Brain condition (i.e. Cerebral Palsy, stroke)

Bleeding or clotting disorders

Diabetes

Fatigue & Immune Deficiency

Joint & bones complications (i.e. hip dysplasia, arthritis)

Epilepsy

Muscular

Heart condition

Neurological condition

Pulmonary condition

Skin break down or pressure sores

N/A

Given your previous answer, please provide date(s) of occurrence and details.

In the past 12 months, has the participant...(Required)

Been hospitalized for any serious injury, condition or surgery?

Experienced loss of consciousness, including seizures?

Experienced a psychotic crisis?

Needed assistance to maintain an upright sitting position or control of his/her head?

Had to have activities restricted due to medical reasons?

N/A

Given your previous answer(s), please explain

Does the participant have a(n)(Required)

Asthma

Inhaler

EpiPen

N/A

Please list any allergies and severity of reactions

Participation Readiness

This information helps our team ensure safe participation and appropriate equine pairing. All details provided are maintained as confidential and accessed only by authorized personnel.

Hearing

Vision

Communication

Circulation

Cognitive Development

Emotional or Psychological

Behavior

Other

Does the participant take any medications(Required)

Yes

Please list medications

Does the participant use any medical devices?(Required)

Yes

Please list medical devices

Is the participant up to date on his/her tetanus shot?(Required)

Yes

Date of last tetanus shot

MM slash DD slash YYYY

Emergency Contact Information

In case of an emergency medical situation while at Agape, or while participating in a program of Agape, please complete the following information.

Primary Emergency Contact(Required)

First Last

Relationship to Participant

Phone Number(Required)

Household

This person lives in the same household as the participant.

Secondary Emergency Contact

First Last

Relationship to Participant

Phone Number

Household

This person lives in the same household as the participant.

Primary Care Physician Name

First Last

PCP Phone Number

Preferred Medical Facility/Hospital

Information for Emergency Medical Providers

Please enter information pertaining to allergies, medications, pre-existing medical conditions that will assist the providers and staff in case of an emergency.

Registration Submission Review

Please review your information before proceeding to the consents.

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Emergency Medical Policy

In the event emergency medical aid/treatment is required, Agape Therapeutic Riding Resources, Inc. will:

Contact 911, state the nature of the emergency and request that an ambulance be sent to the scene of the occurrence;
Contact the person(s) listed above in the priority listed; and
Provide the information listed above to emergency medical providers.

Emergency Medical Policy Consent(Required)

I agree to the Emergency Medical Policy.(Required)

Photo & Media Consent

Agape Therapeutic Riding Resources, Inc. requests that the Agape participant consent to, and authorize the use and reproduction of any and all photographs and any other audio-visual materials taken of the above listed by Agape for publication in promotion material, educational activities, exhibitions, publications, broadcasts, website and any other use which promotes Agape Therapeutic Riding Resources, Inc. and its programs.

Photo & Media Consent

Yes, I authorize the use and reproduction of any and all photographs and any other media taken of the above listed participant and/or individuals

No, I do not authorize the use and reproduction of any and all photographs and any other media taken of the above listed participant and/or individuals.

Equine Activity Release, Assumption of Risk, and Agreement to Indemnify

This Equine Activity Release, Assumption of Risk and Agreement to Indemnify (the “Agreement”) is hereby entered by on the dates indicated below.

A. Scope of Services Provided. Agape Therapeutic Riding Resources, Inc. (“Agape”) is a not-for-profit organization that sponsors, organizes and/or provides facilities for activities involving equines including, but not limited to, therapeutic riding and equine-facilitated learning programs with such activities taking place both on the premises owned by Agape (“Premises”) and at other locations within the State of Indiana (“Locations”) (collectively “Agape Equine Activities”).

B. Inherent Risks of Equine Activities. The undersigned expressly understands that certain dangers or conditions are an integral part of such Agape Equine Activities including but not limited to: i) The propensity of an equine to behave in ways that may result in injury, harm, or death to persons on or around the equine, ii) The unpredictability of an equine's reaction to such things as sound, sudden movement, unfamiliar objects, people, or other animals, iii) Hazards such as surface and subsurface conditions, iv) Collisions with other equines or objects and v) The potential of a person involved in Agape Equine Activities to act in a negligent manner that may contribute to injury to that person and/or other persons, such as by failing to maintain control over an equine. The undersigned expressly understands and agrees that such dangers or conditions exist whether a person is: i) personally engaging in Agape Equine Activities, ii) a spectator of Agape Equine Activities or iii) entering, departing or being on the Premises or Locations where Agape Equine Activities are taking place and that by doing any of these actions, such a person is a “Participant.”

C. Assumption of Risk, Release and Waiver of Liability and Indemnity Agreement. In consideration of Agape allowing the undersigned, as well as those persons for whom the undersigned has listed herein, to be a Participant and with an understanding of the Inherent Risks of Equine Activities as set forth in Paragraph B above, the undersigned, individually and on behalf of each persons listed herein by the undersigned, hereby assumes all such risks and forever releases, waives, discharges and covenants not to sue Agape Therapeutic Riding Resources, Inc. (including its directors, officers, shareholders, employees, agents, representatives, volunteers, insurers, affiliates, successors, assigns and others acting on Agape Therapeutic Riding Resources, Inc.’s behalf including, without limitation, independent contractors such as trainers, instructors, veterinary personnel, farriers, equine care providers and maintenance personnel) (collectively the “Released Parties”) from all liability, loss, claims, demands, possible causes of action, court costs, attorneys' fees and other expenses, known or unknown, anticipated or unanticipated, that may result from any loss, damage or injury (including death) to the person or property of i) the undersigned and ii) each person listed herein by the undersigned which, in any way, results from, or arises in connection with, or relates to, any Agape Equine Activity whether caused by the negligence of the Released Parties or others. The undersigned further hereby agree to indemnify and hold harmless the Released Parties and each of them from any and all loss, liability, damage or cost they may incur due to the undersigned and each person listed herein by the undersigned being a Participant whether caused by the negligence of the Released Parties or otherwise. The undersigned agrees that the Indemnification Agreement shall also apply as to any loss, liability, damage or cost incurred by persons and their property who have not executed an Equine Activity Release, Assumption of All Risk and Agreement to Indemnify but who the undersigned invited or otherwise encouraged to be a Participant.

D. Binding Effect. This Agreement shall be binding upon the heirs, executors, administrators, agents, insurers and assigns of the undersigned and shall inure to the benefit of and may be enforced by the Released Parties. If this Agreement is executed for and on behalf of a Participant who is under the age of eighteen (18) or under some other legal disability, the undersigned hereby represents and warrants that he or she is in fact the legal parent or guardian of said Participant with full rights of custody and control and that this Agreement and all terms contained herein is given on behalf of and is intended to be binding upon said Participant, his/her heirs, executors, administrators, agents, insurers and assigns.

E. Complete Agreement, Choice of Law, Venue and Attorneys Fees. The terms of this Agreement contain the entire agreement of the parties as to the subject matter set forth herein and shall be governed by the laws of the State of Indiana. In the event any provision of this Agreement is deemed to be invalid or unenforceable by any court or administrative agency of competent jurisdiction, then the Agreement shall be deemed to be restricted in scope or otherwise modified to the extent necessary to render its provisions valid and enforceable. The parties agree that Hamilton County, Indiana is the exclusive venue for any legal proceedings arising from or related to this Agreement and the Released Parties shall be entitled to recover the costs incurred (including reasonable attorneys fees) from the undersigned in the event that any legal action (regardless of whether a lawsuit is filed) is required to enforce this Agreement.

I have read, acknowledge, and accept the following:(Required)

Equine Activity Release, Assumption of Risk and Agreement to Indemnify

I have fully read and fully understand this equine activity release and waiver of liability, assumption of all risk and agreement to indemnify. I understand that, by signing this document, I may be waiving and releasing certain important rights which I might have if I did not sign this agreement. I am signing this document voluntarily and without any coercion.

Signature

Please sign here to acknowledge that you have completed this form to the best of your knowledge.

Date

MM slash DD slash YYYY

Equine-Assisted Services

For Individuals

For Groups

One-Time Experiences

Who We Serve