RIDER APPLICATION Step 2. Medical & Release FormPlease fill out the form below and click the Submit and Continue button to continue to the Personal & Developmental Form. Applicant's Name * First Name Last Name MEDICATIONS Please list the rider's prescribed medications and over-the-counter medicines including dosage and frequency PHYSICAL FUNCTION (i.e. Mobility skills such as transfers, walking, driving, bus riding, etc.) * PSYCHOLOGICAL FUNCTION (i.e. Work/school including grade completed, leisure interests, relationships, family structure, support systems, companion animals, fears/concerns, etc.) * GOALS (i.e. Why are you applying for participation? What would you like to accomplish?) * LIABILITY RELEASE * Yes, I am aware of the risks and exposures to personal injury involved through equestrian activities, I hereby release Center for Therapeutic Riding on the East End (CTREE) and Topping Riding Club and its employees assisting in any official capacity on their behalf, from all and every claim for damages which may occur to me/my child/minor under my guardianship or property in any connection with any lesson, clinic, practice, schooling or any work with horses on the stable grounds or away from the grounds of the Topping Riding Club, Sagaponack, New York. PHOTOGRAPHY RELEASE * YES, I hereby irrevocably consent to allow Center for Therapeutic Riding on the East End (Ctree) to use the photograph(s) and/or video(s) of me/my child/minor under my guardianship for any purpose, and in any manner, including without limitation to print media, television, exhibition, publication and any trade or advertising purpose, providing such uses are not made so as to constitute a direct endorsement by me of any product or service. NO, I hereby irrevocably do not consent to allow Center for Therapeutic Riding on the East End (Ctree) to use the photograph(s) and/or video(s) of me/my child/minor under my guardianship for any purpose, and in any manner, including without limitation to print media, television, exhibition, publication and any trade or advertising purpose, providing such uses are not made so as to constitute a direct endorsement by me of any product or service. By signing my name below, I understand and agree to all statements above. * Enter your full legal name (Client or Parent/Legal Guardian) Relationship to Applicant * Signer's Email Address * Date MM DD YYYY
