Thank you for your consideration of joining Justin’s Place in learning about equine assisted services! Filling out this application does not guarantee acceptance into Justin’s Place instructor in training program. You must be 18 by the time of program start in order to be accepted. Please direct any further questions to hello@justinsplaceky.com

Name

First Name

Last Name

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

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Phone

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Email

Secondary Phone

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Employer / School

How did you learn about the program?

Last Tetanus Shot

Please consult with your physician or medical department if you are not up do date in order to decrease risk.

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Health History

Please describe your current health status, particularly regarding the physical/emotional demands of working in an equine=assisted program. Address fitness, cardiac, respiratory, bone or join function, and recent hospitalizations/surgeries.

Allergies

Medications

Please include any medications you'd like us to know you're taking in case of emergency.

Please provide a description of your equine experience including riding experience, volunteer experience, and education.

Please describe why you are interested in completing our instructors in training program.

Confidentiality Agreement

I understand that all information (written and verbal) about participant at this center is confidential and will not be shared with anyone without expressed written consent of the participant and his/her parent/guardian in the case of a minor.

I agree

I do not agree

Photo Release

I consent to and authorize the use and reproduction by Justin's Place of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.

I do consent

I do not consent

By typing my name below I understand the information provided above is accurate to the best of my knowledge. I know of no reason why I should not participate in this center's program.

First Name

Last Name

Todays Date

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Therapeutic Riding Instructor Program Application