Recovery & Discovery Application Form

PLEASE NOTE

Sessions are all private sessions – just the participant, program facilitator and the herd.

No experience with or knowledge of horses is required. All activities are on the ground – no horse riding is involved.

Completing this form does not guarantee you a place in a program or commit you to a program in any way.

Once you’ve submitted your form we’ll be in touch to arrange for you to visit the sanctuary and meet your program facilitator.

Your First & Last Name

Your Email

Best Contact Number

Your Age

How did you hear about the program?

Your Suburb

Do you have any injuries, disabilities or medical conditions that we need to be aware of to keep you safe?

Yes No

If you answered Yes above, please provide some details.

Please tell us a little bit about you, why you are seeking support through this type of program (no specific details are required, just an overview) and what you are hoping to gain from the program. This information is held in strict confidence - only the program coordinator and mentor have access to your answers.

Are you able to pay for your program or do you require a scholarship?

I am able to pay for the program myself ($80 per session) I will be using NDIS Funding for the program ($80 per session) I have a current Health Care Card and need a full scholarship I do not have a current Health Care Card but would like to apply for a part-scholarship as I would find $80 per week too much to pay at the moment.

If you require a part-scholarship, how much per week are you able to comfortably contribute toward the cost of your program?

Please tell us about your availability. Include details about days and times that you can and cannot attend program sessions. For example: "I am available only during school hours", or "I am only available on weekends", or "I am totally flexible and can attend any days and times".

Please provide the name and contact number for an Emergency Contact person

What relationship to you is your Emergency Contact person?

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.