Rider Registration form - Loudoun Therapeutic Riding

LTR Ride-a-Thon RIDER Registration – Saturday, October 8, 2016

General Information for Ride-a-Thon Participant:

LTR Rider’s First Name

LTR Rider’s Last Name

Home Phone

Cellular Phone

Please indicate number of family members walking with rider’s team:

Primary Contact Email

Address Line 1

City

State

Postal Code

Rider’s t-shirt size (T-shirt included included with registration)

Preferred ride time:

Special information: Please note anything below that applies including medical conditions/ allergies/behaviors and/or any precautions or limitations:

Parent/Guardian/Caregiver Information/REQUIRED IF PARTICIPANT IS UNDER 18

Mother/Guardian

First Name

Last Name

Father/Guardian

First Name

Last Name

Phone (if different from above)

Email (if different from above)

If different from above: Address Line 1

City

State

Postal Code

Releases

PHOTO RELEASE: Consent to and authorize the use and reproduction by Loudoun Therapeutic Riding Foundation, Inc. of any and all photographs and any other audio/visual materials taken of me and/or my child for promotional material, social media, educational activities, exhibitions or for any other use for the benefit of the program.

Photo release:

First Name

Last Name

Today’s Date

Signature: (Type name to sign photo release – required)

Today’Date

Thank you!

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