Pony Tales Program Application Form

PLEASE NOTE

Completing an application form does not guarantee that your child will be offered a place in the program.

How did you hear about the program?

Your First & Last Name

Your Emai Address

Best Contact Number

Your Child's Age

Your Child's First & Last Name

School Year

I confirm that my child is in either Prep or Year 1

Attendance

I confirm that my child is available to participate every week.

Trauma History

I confirm that my child has experienced childhood trauma.

Please tell us a little about your child's circumstances and why you believe your child should be selected to be part of the Pony Tales program?

Which school does your child attend?

Child’s current home reading level (if known):

How does your child learn best?

Does your child have any special needs or life-threatening allergies that we may need to know about?

Is there anything else you would like us to know about your child?

Finally, we are interested in the value that parents would put on this program as well as their ability to contribute toward the cost. Please let us know (a) what you think a reasonable fee per week would be if this was a paid program and if money was no issue to you , and (b) how much you could comfortably donate each week if your child was offered a place. Please be assured that your answers to this question will not be taken into account when offering places - we are gathering information only.

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 on behalf of myself and my child/children.

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 on behalf of myself and my child/children.