Meditate and Create Program Application Form

PLEASE NOTE

Completing your application form does not guarantee that you will be offered a place in the program. We will try to schedule classes to accommodate everyone but this is not always possible. We will be running the program 4-6 times a year and you will be prioritised for a place in future programs if not offered a place in the current rounds.

Your First & Last Name

Best Contact Number

Your Age

How did you hear about the program?

The cost is $80 per round ($20 per session) payable in advance. The program is free for those who have a current Health Care Card and are experiencing financial hardship. Please let us know if you:

Are able to pay for your program in full (we will email you an invoice once your place is confirmed) Need some financial support but can pay a $5-10 donation each week to cover the cost of materials Are not able to contribute to the cost of the program

This program involves gentle movement, meditation and physical engagement with a variety of creative media. Please provide information regarding any health issues which may impact your safe participation in the program. Sharing this information with us will help us to modify the activities if needed.

With regard to any information provided in the previous question, are you accessing any professional treatment (e.g. physiotherapy)

Yes No Not applicable

If you answered Yes above, please provide some details.

Please let us know if there are any strategies that we can implement that may help you (if relevant).

Please let us know if you have any allergies that we need to be aware of.

Briefly describe what you hope to gain from this program.

Emergency Contact Person

Emergency Contact's Phone Number/s

Emergency Contact Person's Relationship to you

Is there any other information you feel is relevant to your participation in the program.

RELEASE AND WAIVER OF LIABILITY - INTERACTIONS WITH HORSES: Because there are horses at the sanctuary that you may interact with during you visits, we ask that you sign the following waiver. In consideration for being permitted to enter this property and participate in any way in horse activities, I, the undersigned acknowledge and accept that;• Horse activities can be dangerous and horses can act in sudden and unpredictable (changeable) ways, especially if frightened or hurt.• There is significant risk that serious injury or death may result from horse activities. I furthermore confirm I am aware of the obvious risks associated with activities involving horses and I knowingly and freely assume all such risks. I voluntarily participate at my own risk and assume sole responsibility for any injury, death or property damage I may suffer that arises from my participation in horse related activities.I understand and acknowledge the dangers associated with the consumption of alcohol or any mind altering drugs before and during the activity and take full responsibility for any injury, loss or damage associated with their consumption. I agree not to drink alcohol or take drugs prohibited by law before or during this activity.I agree to follow the directions given to me and that any misconduct or refusal by me to follow any direction can result in the CANCELLATION of participation in the activity and my immediate removal from the vicinity of any horse. I understand that any such non-compliance may result in injury, death and/or permanent disability and I agree to indemnify Kanyini Connections Ltd against all claims made by any person as a result of my failure to comply.I agree that I am solely responsible for my actions.I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS AND AGREE NOT TO Kanyini Connections Ltd, their volunteers, program facilitators, agents and/or employees, other participants, land owners, lessors of premises WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH or LOSS OR DAMAGE TO PERSON OR PROPERTY.I agree that this waiver will apply immediately and will cover all future visits to the sanctuary. *

I understand this waiver and understand that by checking this box and submitting my application, I am agreeing to it.

RELEASE AND WAIVER OF LIABILITY - COVID-19: I acknowledge and agree that I am not covered by Hoofbeats Sanctuary Insurance in the event I catch COVID-19 whilst visiting the sanctuary. I agree to waive legal claims I may have if I contract COVID-19 while visiting Hoofbeats Sanctuary. I agree that this waiver will apply immediately and will cover all future visits to the sanctuary.

I understand this waiver and understand that by checking this box and submitting my application, I am agreeing to it.