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MINI CLINIC APPLICATION -MARCH 15TH
NickaJack Farms, North Lawerance, Ohio
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Indicates required field
Name
*
First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
PHONE NUMBER:
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ALT. PHONE NUMBER:
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Email
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DATE OF BIRTH:
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GENDER
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MALE
FEMALE
Participated in Previous Downunder Horsemanship Clinics? Or Private Lesson?
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yes
no
If Yes, Dates Participated:
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NWC Member (No Worries Club)
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Yes
No
CLINIC DETAILS
DATES: MARCH 15TH
# OF HOURS:
3.5
TOTAL PRICE:
$200.00 (100% OF FEE DUE WITH APPLICATION)
I UNDERSTAND I AM RESPOSIBLE FOR ALL TRAVEL EXPENSES, INCLUDING BUT NOT LIMITED TO: MILEAGE
HORSE INFORMATION:
HORSE NAME:
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HORSE SEX:
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MARE
GELDING
NO STALLIONS ALLOWED
HORSE AGE:
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HORSE BREED
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POLICIES:
PERSONAL PHOTOS: Photos are meant to be for your personal use only, not for commercial purposes or public viewing.
ABSOLUTELY NO VIDEO CAMERAS.
OTHER POLICIES:
NO STALLIONS, MULES OR DONKEYS ALLOWED.
APPROPRIATE FOOTWEAT IS REQUIRED AT ALL TIMES DURING THE CLINC.
BY SIGNING HERE, I ACKNOWLEDGE AND AGREE TO THE ABOVE POLICIES. (MUST BE OF THE AGE OF 18YRS OLD TO SIGN)
ELECTRONIC SIGNATURE:
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MUST BE AGES 18 YRS OR OLDER TO SIGN.
MEDICAL HISTORY & EMERGANCY CONTACT
CLINIC DATE ATTENDING
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JULY 20TH
AUG. 17TH
WHO DO WE CONTACT INCASE OF AN EMERGANCY?
Emergency Contact Name
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First
Last
Em. Phone Number
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RELATIONSHIP TO YOU:
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HAS YOUR DOCTOR PLACED ANY RESTRICITON ON YOUR ACTIVITIES?
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NO
YES
IF YES, PLEASE EXPLAIN:
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ARE THERE ANY REASONS WHY YOU SHOULD NOT PARTICIPATE IN THIS LESSON?
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NO
YES
IF YES, PLEASE EXPLAIN:
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MEDICATIONS: (NAME/DOSE/FREQUENCY)
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DO YOU HAVE ALLERGIES?
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IF YES, PLEASE EXPLAIN:
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DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING IN THE LAST 12 MONTHS?
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ANEMIA
ASTHMA
BLOOD CLOTS
CONVULSIONS
DEPRESSION
DIABETES
EMPHYSEMA
EPILEPSY
FAINTING
HEAD INJURY
SURGERIES
UNCONSCIOUSNESS
HYPOGLUCEMIA
IMPAIRED HEARING
IMPAIRED VISION
INFECTIOUS DISEASE
MENTAL ILLNESS
MUSCKE/JOINT DISORDER
NECK/BACK INJURIES
NEED SOECIAL EQUIPMENT
CURRENT PREGNANCY
SEVERE PAIN
HEART/CARDIAC CONDITION
HIGH BLOOD PRESSURE
NONE OF THE ABOVE
I ACKNOWLEDGE THE CLINIC WILL BE PHYSICALLY DEMANDING AND I AM ABLE TO PARTICIPATE. ELECTRONIC SIGNATURE:
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MUST BE 18YRS OR OLDER TO SIGN. IF A MINOR PLEASE TYPE FULL NAME - PARENT SIGNATURE
REQUIREMENTS AND CHECKLIST
I UNDERSTANF THAT THIS IS A PHYSICALLY DEMANDING CLINIC. I AM HEALTHY AND ABLE TO PARTICIPATE IN THE CLINIC.
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Yes
No
I AM CONFIDENT RIDING MY HORSE ON A LOOSE REIN AT THE WALK, TROT, AND CANTER IN A GROUPD SETTING.
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Yes
No
I AM CONFIDENT CANTERING MY HORSE ON A LOOSE REIN IN A GROUP SETTING WTH OTHER HORSES.
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Yes
No
I AM PARTICIPATING ON A HORSE, NOT A DONKEY OR MULE
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Yes
No
MY HORSE IS A MARE OR GELDING.
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Yes
No
MY HORSE IS NOT A STALLION
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Yes
No
REQUIRED EQUIPMENT
I UNDERSTAND THAT I NEED TO HAVE THE FOLLOWING EQUIPMENT IN ORDER TO PARTICIPATE IN THE CLINIC. I UNDERSTAND THAT THE METHOD AMBASSADOR WILL NOT BRING PRODUCT THAT IS AVAILABLE FOR PURCHASE.
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Yes
No
RIDING BOOTS. PROPER RIDING BOOTS WITH A HEELARE REQUIRED. NO FLIP FLOPS, TENNIS SHOES OR FOOTWEAR OTHAN APPROVED RIDING BOOTS WILL BE ALLOWED IN THE ARENA.
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Yes
No
DOWNUNDER HORSEMANSHIP ROPE HALTER AND 14' LEAD ROPE.
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Yes
No
HANDY STICK AND STRING' STICK AND DETACHABLE 6' STRING
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Yes
No
BRIDLE WITH SNAFFLE BIT AND CHIN STRAP (MECATE REINS OR LOOP REINS WITH A SPANKER ARE HIGHLY RECOMMENDED.) NO SHANK BITS
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Yes
No
A WELL FITTING SADDLE AND PAD WITH CORRECTLY SIZED GIRTH.
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Yes
No
THERE ARE SPECIFIC ISSUES OR CONCERNS I HAVE REGARDING MY RIDING ABILITY OR MY HORSES ABILITY. PLEASE EXPLAIN:
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I CERTIFY THAT I HAVE READ THE ABOVE REQUIREMENTS AND INFORMATION PRESENTED TO ME ABOVE. ELECTRONIC SIGNATURE:
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MUST BE 18 YRS OR OLDER TO SIGN. FOR MINORS, PLEASE TYPE FULL NAME - PARENT SIGNATURE.
CLINIC POLICIES
PERSONAL PHOTOS:
PHOTOS ARE MEANT TO BE FOR YOUR PERSONAL USE ONLY, NOT FOR COMMERCIAL PURPOSES OR PUBLIC VIEWING.
ABSOLUTELY NO VIDEO CAMERAS!
OTHER POLICIES:
NO STALLIONS, MULES OR DONKEYS ALLOWED.
APPROPRIATE FOOTWEAR IS REQUIRED AT ALL TIMES.
PAYMENT POLICY:
50% OF FEES ARE REQUIRED AT SIGN UP. CLINIC MUST BE PAID IN FULL 30 DAYS PRIOR TO START DATE. THIS INCLUDES ALL TRAVEL EXPENSES.
PAYMENTS MUST BE MADE TO KAYLA SCHLABACH, 1179 HARRISON RD. SHREVE, OH 44676. OR PAYPAL:
[email protected]
. CONTACT KAYLA SCHLABACH BOSSLER-METHOD AMBASSADOR AT 330-284-7624 FOR MORE DETAILS.
REFUND POLICY:
IF YOU NEED TO CANCEL, EFFORTS WILL BE MADE BY KAYLA SCHLABACH- METHOD AMBASSADOR TO FILL YOUR CLINIC DATES WITH ANOTHER CLINIC. KAYLA SCHLABACH BOSSLER-METHOD AMBASSADOR RESERVES THE RIGHT, IF YOUR DATES ARE FILLED, YOUR FEES WILL BE RETURNED MINUS ADMINISTRATION FEES.
ALL CANCELLATIONS ARE SUBJECT TO:
* CANCELLATION 120 DAYS BEFORE THE CLINIC: 50% DEPOSIT REFUNDED.
* CANCELLATION 120-60 DAYS BEFORE CLINIC: 25% DEPOSIT REFUNDED LESS $250 ADMINISTRATION FEE.
* CANCELLATION 60 DAYS OR FEWER BEFORE CLINIC: NO REFUND.
CANCELLATION POLICY:
KAYLA SCHLABACH BOSSLER - METHOD AMBASSADOR RESERVES THE RIGHT TO CANCEL A CLINIC DUE TO UNFORSEEN CIRCUMSTANCES BEYOND OUR CONTROL. SUCH DECISIONS WILL BE MADE AT LEAST TWO WEEKS BEFORE THE SCHEDULED CLINIC DATE. IF A CLINIC IS CANCLED BY KAYLA SCHLABACH BOSSLER - METHOD AMBASSADOR. YOU WILL ENTITLED TO A FULL CLINIC REFUND.
TRAVEL EXPENSES:
ALL TRAVEL RESERVATIONS ARE MADE BY KAYLA SCHLABACH BOSSLER - METHOD AMBASSADOR. EVERY EFFORT TO FIND THE MOST REASONABLE AND COST EFFETIVE METHOD OF TRAVEL IS MADE FOR EACH CLINIC. THE METHOD AMBASSADOR OFFERS THE OPTION OF LODGING WITH THE CLINIC HOST TO REDUCE COST. HOST IS RESPONSIBLE FOR THE METHOD AMBASSADOR MEALS. THE METHOD AMBASSADOR WILL WORK WTH EACH CLINIC HOST ON THESE DETAILS.
I AGREE TO THE ABOVE POLICIES BY INITIALING HERE:
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APPLICATION POLICY:
THIS APPLICATION NEEDS TO BE COMPLETED BY EACH PARTICIPANT IN THE CLINIC AND PROVIDED TO THE METHOD AMBASSADOR 30 DAYS PRIOR TO THE CLINIC START DATE.
KAYLA SCHLABACH-BOSSLER
CLINTON ANDERSON METHOD AMBASSADOR
6495 BLOUGH AVE. S.W
NAVARRE, OHIO 44662
[email protected]
330-284-7624
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