keeping pacea n.j. non-profit corporation providing ... filekp sap1 2-09 keeping pace, a n.j....
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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: ___________________________________________________
BY SIGNING BELOW I HEREBY RELEASE, DISCHARGE, AND HOLD HARMLESS KEEPING PACE, ITS DIRECTORS, OFFICERS, EMPLOYEES, AND AGENTS 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