KP SAP1 2-09 Keeping Pace, a N.J. Non-Profit Corporation Providing scholarships for horse enthusiasts with special needs P.O. Box 2362 e-mail address Princeton, NJ 08543 [email protected] Registration Form This application must be completed by the individual if he/she is a legally competent adult age 18 or over, or by his/her parent or legal guardian. Participation in equine assisted activities and therapies has inherent risk. No liability can be accepted by, or expected of this organization, its personnel, or Board of Directors. Completion of this form by the individual if he/she is a legally competent adult age 18 or over, or by his/her parent or legal guardian constitutes agreement that KEEPING PACE is strictly a scholarship providing organization and accepts no liability for participation in equine assisted activities and therapies. Participant’s Name: _____________________________ Date of Birth: ___/___/___ Age: ____ Parent’s/Legal Guardian’s Name: ___________________________________________________ Parent’s/Legal Guardian’s Information Address: ___________________________________________________ Street ___________________________ _________ ____________ City/Town State Zip Code Phone: Home: (______) ____________________________ Cell: (______) ____________________________ Work: (______) ____________________________ E-Mail Address: ___________________________________________________ Participant’s Diagnosis/Diagnoses: ___________________________________________________ ___________________________________________________ Date of Onset of Disability: ___________________________________________________ Form Completed By (Please Print): ___________________________________________________ Relationship to Participant: ___________________________________________________ B Y SIGNING BELOW I HEREBY RELEASE , DISCHARGE , AND HOLD HARMLESS K EEPING P ACE , ITS D IRECTORS , O FFICERS , E MPLOYEES , AND A GENTS FROM ANY CLAIMS ARISING FROM OR RELATING TO ANY HARM OR INJURY THAT MAY RESULT FROM EQUINE ASSISTED ACTIVITIES OR THERAPIES . ________________________________________________________ _____________________ Signature of Person Completing This Form Date