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HEALTH AND DEVELOPMENT FORM:

Please fill this form out to the best of your ability.  This form helps us ensure that your child has a positive and safe experience while riding!

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

1. Tell us a little about your child's personality *

2.  Do you have any concerns regarding the following areas of health and development:

Communication skills (being able to express themselves, difficulty understanding them, limited vocabulary or verbal skills*
No
Yes
Fine motor skills (lacing beads, tying shoes, holding a pencil)*
No
Yes
Gross motor skills (hopping, jumping, running, catching and throwing a ball)*
No
Yes
Vision or hearing difficulties*
No
Yes

If you answered yes to any of these questions, please elaborate so that we can support your child:

3. Does your child have any other medical concerns that would relate to their experience today such as: *Fear of heights *Asthma or breathing difficulties *Seizure disorders *Diabetes

·  Please note, this form is intended for us to get to know your child and their specific interests and needs.  Your privacy is always respected and you do not have to disclose any medical information on this form if you do not choose to.

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

1. Tell us a little about your child's personality *

2.  Do you have any concerns regarding the following areas of health and development:

Communication skills (being able to express themselves, difficulty understanding them, limited vocabulary or verbal skills*
No
Yes
Fine motor skills (lacing beads, tying shoes, holding a pencil)*
No
Yes
Gross motor skills (hopping, jumping, running, catching and throwing a ball)*
No
Yes
Vision or hearing difficulties*
No
Yes

If you answered yes to any of these questions, please elaborate so that we can support your child:

3. Does your child have any other medical concerns that would relate to their experience today such as: *Fear of heights *Asthma or breathing difficulties *Seizure disorders *Diabetes

·  Please note, this form is intended for us to get to know your child and their specific interests and needs.  Your privacy is always respected and you do not have to disclose any medical information on this form if you do not choose to.

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

1. Tell us a little about your child's personality *

2.  Do you have any concerns regarding the following areas of health and development:

Communication skills (being able to express themselves, difficulty understanding them, limited vocabulary or verbal skills*
No
Yes
Fine motor skills (lacing beads, tying shoes, holding a pencil)*
No
Yes
Gross motor skills (hopping, jumping, running, catching and throwing a ball)*
No
Yes
Vision or hearing difficulties*
No
Yes

If you answered yes to any of these questions, please elaborate so that we can support your child:

3. Does your child have any other medical concerns that would relate to their experience today such as: *Fear of heights *Asthma or breathing difficulties *Seizure disorders *Diabetes

·  Please note, this form is intended for us to get to know your child and their specific interests and needs.  Your privacy is always respected and you do not have to disclose any medical information on this form if you do not choose to.

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

1. Tell us a little about your child's personality *

2.  Do you have any concerns regarding the following areas of health and development:

Communication skills (being able to express themselves, difficulty understanding them, limited vocabulary or verbal skills*
No
Yes
Fine motor skills (lacing beads, tying shoes, holding a pencil)*
No
Yes
Gross motor skills (hopping, jumping, running, catching and throwing a ball)*
No
Yes
Vision or hearing difficulties*
No
Yes

If you answered yes to any of these questions, please elaborate so that we can support your child:

3. Does your child have any other medical concerns that would relate to their experience today such as: *Fear of heights *Asthma or breathing difficulties *Seizure disorders *Diabetes

·  Please note, this form is intended for us to get to know your child and their specific interests and needs.  Your privacy is always respected and you do not have to disclose any medical information on this form if you do not choose to.

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

1. Tell us a little about your child's personality *

2.  Do you have any concerns regarding the following areas of health and development:

Communication skills (being able to express themselves, difficulty understanding them, limited vocabulary or verbal skills*
No
Yes
Fine motor skills (lacing beads, tying shoes, holding a pencil)*
No
Yes
Gross motor skills (hopping, jumping, running, catching and throwing a ball)*
No
Yes
Vision or hearing difficulties*
No
Yes

If you answered yes to any of these questions, please elaborate so that we can support your child:

3. Does your child have any other medical concerns that would relate to their experience today such as: *Fear of heights *Asthma or breathing difficulties *Seizure disorders *Diabetes

·  Please note, this form is intended for us to get to know your child and their specific interests and needs.  Your privacy is always respected and you do not have to disclose any medical information on this form if you do not choose to.

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

1. Tell us a little about your child's personality *

2.  Do you have any concerns regarding the following areas of health and development:

Communication skills (being able to express themselves, difficulty understanding them, limited vocabulary or verbal skills*
No
Yes
Fine motor skills (lacing beads, tying shoes, holding a pencil)*
No
Yes
Gross motor skills (hopping, jumping, running, catching and throwing a ball)*
No
Yes
Vision or hearing difficulties*
No
Yes

If you answered yes to any of these questions, please elaborate so that we can support your child:

3. Does your child have any other medical concerns that would relate to their experience today such as: *Fear of heights *Asthma or breathing difficulties *Seizure disorders *Diabetes

·  Please note, this form is intended for us to get to know your child and their specific interests and needs.  Your privacy is always respected and you do not have to disclose any medical information on this form if you do not choose to.

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

1. Tell us a little about your child's personality *

2.  Do you have any concerns regarding the following areas of health and development:

Communication skills (being able to express themselves, difficulty understanding them, limited vocabulary or verbal skills*
No
Yes
Fine motor skills (lacing beads, tying shoes, holding a pencil)*
No
Yes
Gross motor skills (hopping, jumping, running, catching and throwing a ball)*
No
Yes
Vision or hearing difficulties*
No
Yes

If you answered yes to any of these questions, please elaborate so that we can support your child:

3. Does your child have any other medical concerns that would relate to their experience today such as: *Fear of heights *Asthma or breathing difficulties *Seizure disorders *Diabetes

·  Please note, this form is intended for us to get to know your child and their specific interests and needs.  Your privacy is always respected and you do not have to disclose any medical information on this form if you do not choose to.

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

1. Tell us a little about your child's personality *

2.  Do you have any concerns regarding the following areas of health and development:

Communication skills (being able to express themselves, difficulty understanding them, limited vocabulary or verbal skills*
No
Yes
Fine motor skills (lacing beads, tying shoes, holding a pencil)*
No
Yes
Gross motor skills (hopping, jumping, running, catching and throwing a ball)*
No
Yes
Vision or hearing difficulties*
No
Yes

If you answered yes to any of these questions, please elaborate so that we can support your child:

3. Does your child have any other medical concerns that would relate to their experience today such as: *Fear of heights *Asthma or breathing difficulties *Seizure disorders *Diabetes

·  Please note, this form is intended for us to get to know your child and their specific interests and needs.  Your privacy is always respected and you do not have to disclose any medical information on this form if you do not choose to.

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

1. Tell us a little about your child's personality *

2.  Do you have any concerns regarding the following areas of health and development:

Communication skills (being able to express themselves, difficulty understanding them, limited vocabulary or verbal skills*
No
Yes
Fine motor skills (lacing beads, tying shoes, holding a pencil)*
No
Yes
Gross motor skills (hopping, jumping, running, catching and throwing a ball)*
No
Yes
Vision or hearing difficulties*
No
Yes

If you answered yes to any of these questions, please elaborate so that we can support your child:

3. Does your child have any other medical concerns that would relate to their experience today such as: *Fear of heights *Asthma or breathing difficulties *Seizure disorders *Diabetes

·  Please note, this form is intended for us to get to know your child and their specific interests and needs.  Your privacy is always respected and you do not have to disclose any medical information on this form if you do not choose to.

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

1. Tell us a little about your child's personality *

2.  Do you have any concerns regarding the following areas of health and development:

Communication skills (being able to express themselves, difficulty understanding them, limited vocabulary or verbal skills*
No
Yes
Fine motor skills (lacing beads, tying shoes, holding a pencil)*
No
Yes
Gross motor skills (hopping, jumping, running, catching and throwing a ball)*
No
Yes
Vision or hearing difficulties*
No
Yes

If you answered yes to any of these questions, please elaborate so that we can support your child:

3. Does your child have any other medical concerns that would relate to their experience today such as: *Fear of heights *Asthma or breathing difficulties *Seizure disorders *Diabetes

·  Please note, this form is intended for us to get to know your child and their specific interests and needs.  Your privacy is always respected and you do not have to disclose any medical information on this form if you do not choose to.

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

1. Tell us a little about your child's personality *

2.  Do you have any concerns regarding the following areas of health and development:

Communication skills (being able to express themselves, difficulty understanding them, limited vocabulary or verbal skills*
No
Yes
Fine motor skills (lacing beads, tying shoes, holding a pencil)*
No
Yes
Gross motor skills (hopping, jumping, running, catching and throwing a ball)*
No
Yes
Vision or hearing difficulties*
No
Yes

If you answered yes to any of these questions, please elaborate so that we can support your child:

3. Does your child have any other medical concerns that would relate to their experience today such as: *Fear of heights *Asthma or breathing difficulties *Seizure disorders *Diabetes

·  Please note, this form is intended for us to get to know your child and their specific interests and needs.  Your privacy is always respected and you do not have to disclose any medical information on this form if you do not choose to.

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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