Therapeutic Rider Form

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Please fill out the information below.

Participant Name *

Date of Birth

YYYY

Height: Weight: *

Gender *

Male

Female

Other:

Required

Phone *

Address *

Email *

Alternative Phone Number *

Emergency Contact: *

Emergency Number: *

Employer/School *

Parent/Legal Guardian: *

Address (If different from above):

Phone (If different from above)

How did you hear about the program? *

Photo and Video Release: Please select below I Do/I Do Not consent to and authorize the use and reproduction by Walnut Grove Farms of any and all photographs and any other audio/visual materials taken of me for promotional material, education activities, exhibitions or for any other use for the benefit of the program *

I Do

I Do Not

Required

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