Before You Begin

This form takes approximately 15 to 25 minutes to complete depending on the rider's history. Please read through the checklist below and gather everything you need before starting so you can complete it in one session.

1

Rider Identification

Full legal name, date of birth, home address, and contact information for the rider. If the rider is under 18, you will also need the legal guardian's name, contact information, and employer.

2

Medication List

All current medications, both prescription and over-the-counter. For each one you will need the drug name, dosage, how often it is taken, and any known side effects. Up to 5 medications can be listed.

3

Physician & Medical Facility Information

The rider's attending physician name, address, and phone number. Also have the name, address, and phone number of the rider's preferred medical facility in case of emergency.

4

Health Insurance Card

The name of the insurance company, the name of the policy holder, and the policy number.

5

Court Orders (if applicable)

If there is anyone legally prohibited from picking up this rider from the facility, have the relevant court order information available to reference in the form.

A few things to know before you sign: This form includes a Liability Release executed under Texas law (County of Hunt), an Emergency Medical Treatment Authorization, a Photo & Media Release, and an Honesty Declaration. Each section requires an electronic signature, which is legally valid under the Texas Uniform Electronic Transactions Act (Business & Commerce Code, Chapter 322). Please read each section carefully before signing.

Personal Information

All fields marked * are required.

Full Name *

Date of Birth *

Age *

Street Address *

City *

State

Zip Code *

Email Address *

Home Phone

Cell Phone

Work Phone

Place of Employment

School or Educational Institution

If Rider is Under 18

Complete this section only if the rider is a minor.

Legal Guardian(s)

Guardian Email

Guardian Place of Employment

Guardian Home / Cell Phone

Guardian Work Phone

Emergency Contact

Who should we notify in the event of an emergency?

Emergency Contact Name *

Relationship to Rider *

Contact Number *

Medical Information

Please include all prescription and over-the-counter medications. Leave rows blank if not applicable.

#	Name of Drug	Dosage	Frequency	Side Effects
1
2
3
4
5

Allergies to Any Medication

Past and Prospective Surgeries

Physical & Functional Status

Please describe the rider's abilities, any difficulties, and any assistance or equipment required.

Does this rider have any physical disabilities? *

Yes No

Physical Function Description

Rider Abilities

Please indicate the rider's current abilities:

Rider Goals *

Does this rider have any emotional or behavioral concerns? *

Yes No

Emotional & Behavioral History

All information is kept strictly confidential and is used solely to ensure the safety and wellbeing of the rider.

Please indicate any history of the following:

Depression

Yes No

Suicide Attempts

Yes No

Anxiety

Yes No

Eating Disorders

Yes No

Mental Illness

Yes No

Emotional Abuse

Yes No

Physical Abuse

Yes No

Sexual Abuse

Yes No

Addiction

Yes No

Chronic Illness

Yes No

Self Harm

Yes No

Violent Behavior

Yes No

Any history of alcohol or drug abuse?

Yes No

Major Stressors in the Last 12 Months

Psychiatric or Emotional Health Hospitalization

Rider Pickup Authorization

Please list all individuals authorized to pick up this rider from our facility.

Persons Authorized to Pick Up This Rider

Persons NOT Authorized to Pick Up This Rider

Emergency Medical Information

Please provide the rider's physician and preferred medical facility information.

Attending Physician *

Physician Phone

Physician Address

City

State

Zip

Preferred Medical Facility

Facility Phone

Facility Address

City

State

Zip

Health Insurance Company

Name of Policy Holder

Policy Number

Additional Concerns or Information

Photo & Media Release

Please read the statement below and indicate your preference. Your choice does not affect your eligibility to participate in the Divine Path Ranch program.

Divine Path Ranch may photograph or record riders during sessions for use in promotional materials, educational content, exhibitions, or other program-related purposes. You have the right to decline this use at any time.

Please select one of the following options to indicate your preference. A signature is required to confirm your selection, regardless of which option you choose.

Your Photo & Media Preference *

Yes, I consent

Divine Path Ranch may use photographs and audio/visual materials of the rider for program-related purposes.

No, I do not consent

Divine Path Ranch may not use photographs or audio/visual materials of the rider. This does not affect participation in the program.

Confirm Your Selection

Please sign below to confirm that your selection above accurately reflects your preference. This signature is required regardless of which option you chose.

Print Full Name *

Date *

Electronic Signature — Type Your Full Name * This field is required. Please type your full legal name to sign.

Typing your name in this field constitutes your legal electronic signature confirming your selection above.

I confirm that my selection above is accurate and that my typed name constitutes my legal electronic signature, in accordance with the Texas Uniform Electronic Transactions Act (Business & Commerce Code, Chapter 322).

Declarations, Authorizations & Liability Release

Please read each section carefully. Your electronic signature below has the same legal effect as a handwritten signature under Texas law.

Honesty Declaration

I attest that the answers provided throughout this Rider Intake Form have been answered truthfully and completely to the best of my recall. I attest that I have not deliberately or intentionally misrepresented my medical, social, or psychological history in any way with my responses.

Print Full Name *

Date *

Electronic Signature — Type Your Full Name * This field is required. Please type your full legal name to sign.

Typing your name in this field constitutes your legal electronic signature.

I understand and agree that my typed name constitutes my legal electronic signature for the Honesty Declaration, in accordance with the Texas Uniform Electronic Transactions Act (Business & Commerce Code, Chapter 322).

Authorization for Emergency Medical Treatment

In case of medical emergency, the rider or guardian authorizes Divine Path Ranch to secure and retain such emergency medical assistance and transportation as they determine to be necessary and proper. The rider or guardian authorizes release of rider records upon request to the authorized individual or agency involved in the medical emergency treatment. This authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedure deemed "life-saving" by the attending physician. This provision will only be invoked if the guardian cannot be reached.

Authorization for emergency medical treatment is required to participate in the Divine Path Ranch program. By signing below, you are confirming this authorization.

Specific Preferences or Limitations (optional)

Print Full Name *

Date *

Electronic Signature — Type Your Full Name * This field is required. Please type your full legal name to sign.

Typing your name in this field constitutes your legal electronic signature.

I authorize Divine Path Ranch to secure emergency medical treatment on behalf of the rider if the guardian cannot be reached. I understand and agree that my typed name constitutes my legal electronic signature, in accordance with the Texas Uniform Electronic Transactions Act (Business & Commerce Code, Chapter 322).

Liability Release

Executed and signed in the State of Texas, County of Hunt

I acknowledge and accept that horseback riding, care and maintenance of animals, and care and maintenance of the ranch grounds and equipment involve the risk of personal injury. By my signature (and, in case of a minor, the parent's or guardian's signature), I hereby waive all rights, claims, causes of action, and lawsuits against Mr. and Mrs. Michael Jaeckle and Divine Path Ranch, located at 6373 CR 2520, Royse City, Texas 75189, their family, heirs, executors, legal representatives, administrators, successors, assigns, guests, employees, or agents affiliated with any of them, for any injury, liability, or damages which may occur while performing in any activity on said property.

I agree to indemnify, defend, and hold harmless Mr. & Mrs. Jaeckle and Divine Path Ranch for any accident, injury, or loss that might occur, and free such persons from all liability for such injury or loss. I understand that activities with animals and/or riding on horses involve possible danger and I participate at my own risk. I understand that horseback riding can involve activities such as crossing creeks, galloping over uneven terrain, and being in unfamiliar places under adverse weather conditions, which could result in injury to me and/or to the horse I am riding.

I am aware that wearing a certified safety helmet is a good protective measure against head injury, and I understand that helmets are required for all horse riders. My signature constitutes acceptance of the above terms and conditions.

DPR Policy: Please cancel or reschedule at least 48 hours in advance. You will be responsible for the entire session fee if cancellation occurs with less than 48 hours notice. Payment is accepted via Zelle at . 50-minute Group Riding Lesson: $50 | 50-minute EAL Session: $65.

Medical Release: I further agree to allow and be financially responsible for any necessary emergency medical treatment by any available physician at any available medical institution in the event of my injury or illness. I have read and fully understand this Liability Release. I understand that the Texas Equine Liability Act (Chapter 87, Civil Practice and Remedies Code) provides that an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities.

Print Full Name *

Date *

Electronic Signature — Type Your Full Name * This field is required. Please type your full legal name to sign.

Typing your name in this field constitutes your legal electronic signature.

Guardian Signature — Type Full Name (if participant is a minor)

Required only if the rider is under 18.

Street Address *

City *

State

Zip *

Primary Phone Number *

Primary Email Address *

I have read and fully understand this Liability Release. I agree that my typed name constitutes my legal electronic signature, executed in the State of Texas, County of Hunt, in accordance with the Texas Uniform Electronic Transactions Act (Business & Commerce Code, Chapter 322).

Electronic Signature Notice — State of Texas: By typing your full name in each signature field and checking the corresponding acknowledgment box, you are providing your legally binding electronic signature. Under the Texas Uniform Electronic Transactions Act (Business & Commerce Code, Chapter 322), an electronic signature has the same legal effect, validity, and enforceability as a traditional handwritten signature. The date, timestamp, and IP address associated with each submission are automatically recorded for verification purposes. If you have questions about the legal effect of this electronic agreement, please consult a licensed Texas attorney before submitting this form.

Begin the Rider

Intake Process

Rider Intake Form

Confirm Your Selection

Honesty Declaration

Authorization for Emergency Medical Treatment

Liability Release

Form Submitted Successfully