Family Registration and Releases

One Form Per Family

Parent/ Guardian's Name(s):

Address

Phone

If different than above, Emergency contact name.

If different than above, Emergency contact number.

Child's Name:

Date of Birth:

Weight:

Height:

Age:

School:

Grade:

Child's Name:

Date of Birth:

Weight:

Height:

Age:

School:

Grade:

Child's Name:

Date of Birth:

Weight:

Height:

Age:

School:

Grade:

Liability Release (must complete):

(please list all children’s names) that will be participating in Storybook Farm, Inc’s. animal-assisted and nature programs. Animals are unpredictable. I acknowledge the risks and potential risks of interacting with large animals and horseback riding. However, I feel that the benefits to my son/daughter are greater than the risk assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors, and administrators, waive and release forever all claims for damages against Storybook Farm, Inc., its Board of Directors, Instructors, Therapists, Aides, Volunteers and/or Employees for any and/or losses my son/daughter may sustain while participating in any or all Storybook Farm, Inc’s. programs.

Date:

Signature:

Audio/Visual Release:

I hereby consent to and authorize the use and reproduction by Storybook Farm, Inc. of all photographs and any other audiovisual materials taken of me/my son(s)/my daughter(s) for promotional printed material, educational activities or for any other use for the benefit of the program.

Date:

Signature:

Participant History and Inventory

One Form Per Child

Child's Name

Age

Provide Important details regarding your child's participation.

Describe your child's general personality, demeanor, like, and dislikes.

Set goals for your child.

Explain your family structure, support system, and companion animals, if any,

Comment on any additional thoughts or concerns,if any.

Family Authorization for Emergency Medical Treatment

Name

Relationship

Phone

On the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize Storybook Farm, Inc. to:

1. Secure and retain medical treatment and transportation if needed.

2. Release client records upon request to the authorized individual agency involved in the medical emergency treatment.

Content Plan

This authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedure deemed lifesaving by the physician. This provision will only be invoked if the person(s) above is unable to be reached.

Date

Parent or Guardian Signature:

Non-Consent Plan

I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. In the event emergency treatment/ aid is required, I wish the following procedures to take place:

Responce:

Date

Non-Consent Signature of Parent or Guardian

Please Download the Physician's Statement and return by mail.

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Family Authorization for Emergency Medical Treatment

Please Download the Physician's Statement and return by mail.

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