Language
English (US)
Participant Application & Health History
To be filled out by parent or legal guardian if applicant is under 18
Participant Name
*
First Name
Last Name
HIPAA Name
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Ethnicity
*
Please Select
African American
African American/Caucasian
Asian
Caucasian
Hispanic
Hispanic/Caucasian
Native American
Birth Date
*
/
Month
/
Day
Year
Gender
*
Male
Female
Height
*
Weight
*
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How will this student be participating in services at LoveWay?
*
Please Select
Through their school
Through a home-based session
Both
What school will this student be participating through?
*
Please Select
Brookside
Concord Intermediate
Eastwood
Five Little Stones
Goshen Intermediate
Heritage Intermediate (Middlebury)
Mary Beck
Mishawaka Youth
Nappanee
Northridge Middle School
Northridge High School
Orchard View
Prairie View
My school isn't listed
Enter the school below:
*
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Parent/Legal Guardian Name (Required if Participant is Under 18)
First Name
Last Name
Primary Phone
*
Email
*
Is your address different than the student's address listed previously?
*
Yes
No
Parent/Legal Guardian Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Parents' Place of Work
Work Phone
Please enter a valid phone number.
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Diagnosis/Disability
*
Does the participant have any of the following health conditions?
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Please enter any current medications (including over-the-counter meds).
*
Enter N/A if no medications.
Does the participant experience seizures?
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Yes
No
What was the date of the participant's last seizure?
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/
Month
/
Day
Year
Please describe seizures or other limitations in detail.
*
Please describe the participant's functioning ability (example: mobility skills/walking /motor skills/holding objects/communications/speech) and social abilities (example: difficulty relating to others or fearful).
*
I attest that all the information above in this health history is true and accurate.
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Today's Date
*
/
Month
/
Day
Year
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Authorization for Emergency Medical Treatment
In case of an emergency LoveWay, Inc. 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.
Do you consent to emergency medical treatment?
*
I Consent
I Do Not Consent
Preferred hospital
*
Goshen Hospital
Elkhart General Hospital
No preference
Health insurance carrier and policy number
*
List any allergies to medications
*
Please sign below to verify you are declining emergency medical treatment. In order for participants to interact with horses, we need permission to seek treatment in the case of an accident.
*
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Emergency Contacts
Please list at least one person who does not live in your home.
Name
*
First Name
Last Name
Email
*
Phone Number
*
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Physician Contact Information
Doctor's Office
*
Physician Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
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Photo & Media Release
Do you consent to the use by LoveWay, Inc., or local media of any video/photos taken of yourself or your participant/family members during LoveWay, Inc. related activities for promotional, education or program use.
*
I Consent
I Do Not Consent
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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, Therapists, 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.
Signature
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