Program Application

Enroll in a Mending Strides Ranch Program.

Prior to completion of application and payment, email [email protected] to inquire about program availability.

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Select a Program

Program

General Information

Participant's Name

First

Last

Date of Birth

Age

Gender

Nationality

Required for grant applications

Did your Serve in the Military

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone

Home Phone

Employer Name, School Name, or Homeschool

Referral Source, How did you hear about us?

What expectations do you have of the program?

Medical Information

Do you have allergies

Do you experience seizures?

Have you had a Tetanus Shot within last 10 years?

Physician's Name

Physician's Phone

Preferred Hospital

Health Insurance Company

Health Insurance Policy Number

Health Insurance Group Number

In the event of an emergency, is there any information you would like to provide First Responders?

Emergency Contact

Contact Name

Relationship

Phone

Medical Release

In the event emergency medical treatment or aid is required due to illness or injury while present on the property of Mending Strides Ranch, Inc.,

I AUTHORIZE Mending Strides Ranch, Inc., to secure transportation and medical treatment including x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital service rendered under the general or specific instructions of any physician or hospital. The undersigned hereby agrees to pay all fees and expenses of doctors, hospitals, ambulances and other medical expenses reasonably and necessarily incurred. Please understand we will first try to reach the emergency contacts.
I DO NOT AUTHORIZE emergency medical treatment/aid.

Agreements

Photo and Video Release Agreement

I DO CONSENT to and authorize the use and reproduction by Mending Strides Ranch, Inc., of any and all photographs and any other audio/visual materials taken of me/my child for promotional material, educational activities, social media and exhibitions or for any other use for the benefit of the program.
I DO NOT CONSENT to and I do not authorize the use and reproduction by Mending Strides Ranch, Inc., of any and all photographs and any other audio/visual materials taken of me/my child for promotional material, educational activities, social media and exhibitions or for any other use for the benefit of the program.

(Please note that pictures/videos will not be taken during therapy sessions)

Information is Accurate

I understand that the information provided above is accurate to the best of my knowledge. I know of no reason why I/my child should not participate in this center's program.

Medical Treatment

I have read and made a selection for emergency medical treatment as indicated above.

Your Signature (or a Parent or Guardian's signature if you are a minor)

Clear Signature

Your Name (or a Parent or Guardian's name if you are a minor)

Date