Costs *

Payment in full is required at the beginning of each session. This will secure your lesson time throughout the session. Due to the nature of program activity we are not able to offer refunds, make-ups for missed lessons, or carry a balance over from one session to the next. Enter name to legally agree

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Attire *

• Dress for comfort and weather conditions • All participants must wear closed toe shoes for safety; Crocs are not permitted • All participants must wear approved ASTM-SEI safety helmets while doing ground work. Helmets are provided, but if desired participants can bring their own which will be subject to the instructor's approval. Enter name to legally agree

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Safety Rules *

• Children may not be unattended. • Children may not run or play loudly. • Dogs are not allowed. • A parent or care-giver is required to remain onsite during the lesson. • The barn is not open to parents, caregivers or visitors without prior permission. • Guests and spectators should remain in the designated viewing areas to minimize distractions. Enter name to legally agree

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Photo Release *

I consent and authorize to photos taken of myself and participant for promotional materials such as flyers, website and social media.

I do not consent and authorize to photos taken of myself and participant for promotional materials such as flyers, website and social media.

*

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Name *

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Phone *

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Name *

First Name

Last Name

Date of Birth *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

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Consent 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) listed as “emergency contact” is unable to be reached. I agree to pay for or arrange insurance payment for costs and claims Experience Dragonfly Ranch incurs or becomes liable to pay for all medical aid, treatment, and procedures arising from any illness or injury covered by this authorization. Enter name to legally agree

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Date of Consent

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Orthopedic

Contractures

Joint subluxation/dislocation

Pathologic Fractures

Spinal Instability/Abnormalities

Heterotopic Ossification/Myositis Ossificans

Coxa Arthrosis

Osteoporosis

Scoliosis 30 degrees or greater

Spinal Fusion/FixationAtlantoaxialInstability-include neurologic symptoms 


Neurologic

Hydrocephalus/Shunt

Neuromuscular Disorders (if pain or 
fatigue increases with the activity)

Uncontrolled Seizures

Spinal Cord Injury (contraindication if injury is above T-6)

Tethered Cord Symptoms Chiari II Malformations, Hydromyelia Symptoms (all are associated with Spina Bifida)

Medical/ Psychological

Allergies

Physical/Sexual/Emotional Abuse

Dangerous to self or others

Hemophilia

PVD

Animal Abuse

Blood Pressure Control

Exacerbations of medical conditions

Medical instability

Respiratory Compromise 


By signing you accept the terms and conditions outlined in this intake form. *

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Date

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