Participant Application

Participant Application

To be filled out by legal representative of the participant
Participant Info
Participant's Name*

First NameLast Name
HIPAA Name
Age
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Cell Phone
Date of Birth*

MonthDayYear
Ethnicity*
Height*
Weight*
Gender*

MaleFemale
How will this person be participating in services at LoveWay?*
What school will this student be participating through?*
Enter the school below:*

Legal Representative Info
Is participant over 18 and their own Legal Representative?*

NoYes
Legal Representative Name*

First NameLast Name
Please note: The person listed above as the Legal Representative must be the person signing as the Legal Representative throughout this application.
Please note: Since the participant is over 18 and is their own Legal Representative, they must be the person signing as the Legal Representative throughout this application.
I am the participant's*

ParentGuardianCase ManagerOther
File Upload: Please provide documentation showing proof of legal representation

Cancelof
Is your address different than the participant's address listed previously?*

YesNo
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone*
Email*

Registered Nurse Assessment Agreement
The Registered Nurse Form is provided as an option for those who may not be able to have a doctor fill out the full Physician Form at this time. By having a Registered Nurse Form filled out by the participant's school nurse, this can potentially allow them to participate in services.

As we want to ensure the safety of all involved, along with following the policies set by PATH International and Certified Horsemanship Association, please be aware of the following conditions:

1) A complete Participant Application filled out by the participant's legal representative is still required.

2) Participants approved through the Registered Nurse Form are able to participate in unmounted activities only.

3) This form is not applicable for those with a down syndrome diagnosis. A Physician Form is required in those instances.
If needed, I approve for a Registered Nurse from the participant's school to complete the Registered Nurse Form in place of the Physician Form and attest I am the legal representative of the participant.*

YesNo

Health History
Diagnosis/Disability*
Does the participant have any of the following health conditions?*
Please list all allergies:*
Current Medications (Including over the counter meds)*
Enter N/A if no medications.
Describe how the participant's disabilities affect their functional ability (Example: mobility skills, walking, motor skills, holding objects, communication, speech) and include assistance or equipment needs.*
Describe how the participant's disabilities affect their social ability (Example: difficulty relating to others, aggressive behaviors, fearful).*

Authorization for Emergency Medical Treatment
In case of an emergency LoveWay is authorized to secure emergency medical treatment including but not limited to: x-rays, surgery, hospitalization, and medication as recommended by the attending emergency medical personnel. I also agree to the release of any medical records necessary for the timely treatment of a medical emergency.

Consent is required to participate in LoveWay services.
Do you consent to emergency medical treatment?*

I consentI do NOT consent
Preferred hospital*

Goshen HospitalElkhart General HospitalOther
Health Insurance & Policy Number*
Medication Allergies*
Legal Representative Signature*

Clear

Emergency Contacts

Please list one person who does not live in your house
Name*

First NameLast Name
Relation to Participant*
Phone*
Name*

First NameLast Name
Relation to Participant*
Phone*
Physician*

First NameLast Name
Phone*

Photo & Media Release
LoveWay, Inc. and/or the local media may use any photos or videos taken of myself/participant/family members during LoveWay, Inc. related activities for promotional, educational, or program use.*

I consentI do NOT consent
Legal Representative Signature*

Clear

Waiver Agreement & Liability Release
My signature below denotes that I agree to all the following as a condition for myself, my children, and my family as it pertains to LoveWay, Inc. (hereafter referred to as the “Center”) as a condition for participation in activities at/on/near the Center’s premises and property or associated with any Center activity including but not limited to: equine assisted activities, trail riding, arena instruction, barn & pasture activities, demonstrations and public events. WARNING: Under Indiana law, an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities. As the legal representative of the participant (myself/child/family), I acknowledge the risks and potential for risks of equine related activities. I understand not all risks can be foreseen nor prevented. I understand these risks and assume responsibility for them. I hereby, intending to be legally bound for myself, my children and my family, heirs and assigns, executors or administrators, waive and release forever all claims, liabilities and damages (present or future) against LoveWay, Inc., its Board of Directors, Executive Director, Instructors, Staff, Volunteers, Agents and/or other authorized persons for any and all injuries/losses sustained, directly or indirectly while participating and/or visiting at LoveWay, Inc. As consideration for the Center to allow myself, my children, my spouse and my family members to engage in Center related activities, I agree to assume full responsibility for any and all bodily injuries, losses, claims, liabilities, or damages, which I or they might sustain.

It is mutually understood and agreed that the waiver and liability release set forth in this document constitutes a waiver of liability beyond the provisions of the Indiana Equine Activity Liability Act. I further agree to indemnify and hold harmless the Center or persons/entities associated with the Center and to not bring any claim or suit against them on the basis of any exception to the IN Equine Act. Should I breach any part of this waiver/liability release, I agree to pay all of the Center’s attorney’s fees or other legal costs that may occur.

I attest that I am at least 18 years of age, of sound mind, not suffering from shock or under the influence of alcohol, drugs or intoxicants. I have read this ENTIRE waiver and application and fully understand it. I intend for this waiver, agreement and liability release to be valid and binding today and at ALL FUTURE TIMES. I attest that all the information I have provided in this application/medical history is true and accurate. My signature denotes agreement with ALL the information on this form.
Legal Representative Signature*

Clear
Today's Date*

MonthDayYear
Should be Empty:

Participant Application

Participant Info

Legal Representative Info

Registered Nurse Assessment Agreement

Health History

Seizure Questionnaire

Authorization for Emergency Medical Treatment

Emergency Contacts

Photo & Media Release

Waiver Agreement & Liability Release