EQUINE REGISTRATION FORM

A Leader in Equine and Canine Massage Certification

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EQUINE COURSE REGISTRATION

First name

Last name

Street Address

City

Region/State/Province

Postal / Zip code

Phone

Select an option

Female

Male

Birthday

Select a date

Emergency Contact

Phone

EMPLOYMENT HISTORY: Current occupation and title

EDUCATION HISTORY: List schools, colleges, training courses.

Are you a Licensed Massage Therapist?

Yes

Do you currently have a horse?

Yes

Are you currently riding or competing?

Yes

EQUINE EXPERIENCE: Describe your background with horses.

List any clubs or organizations of which you are a member.

HEALTH & SAFETY

This course is physically and mentally strenuous (standing and sitting for long hours, holding heavy horse limbs, reading, studying, testing, etc.)

Do you have any physical limitations or special learning needs? If so, describe fully.

Your Personal Health & Safety

Do you have any medical conditions we need to be aware of

Yes

List Here

**NOTE: Due to strict safety and liability reasons of Therasage EMC and host facilities, if you are pregnant at the time of the selected class you will be required to attend a class at a later date.

This is due to safety and liability reasons that Therasage EMC or the host facility will not be responsible for.

Please check here that you have read this information and understand the requirement.

Acknowledgement

TUITION & PAYMENT

Total cost of tuition is $1,200.00. A $300.00 registration fee is due at the time of enrollment that is non-refundable if student cancels or is a no show. Balance of $900.00 is due the first day of class. Cost includes manual, handouts, and hands-on instruction. Due to the educational aspect and proprietary information associated with Therasage EMC class materials and instruction, there is NO REFUND for anyone who has attended any class or portion of a class.

I understand the policy

Acknowledgement

SIGNED CONSENT

I certify that I am in good health and am fully capable of participating in the Therasage Equine Massage Certification Program, and that the information I have provided in this application is true and factual. If there is any question regarding horse handling experience, Therasage EMC has the right to ask the participant to leave and learn the required handling skills before returning to complete the certification. I acknowledge that horses and ponies are large, unpredictable, strong animals that can cause damage, injury or even death, and that in working on or around horses and ponies, I am accepting this risk, and agree to hold harmless Greg Gage, Therasage EMC. any instructor, and any barn, farm, ranch or horse/pony owner, or anyone else associated with this program.

Your Signature

Today's Date

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