Intentionally Wild Intake Form

Please fill out the intake form before your first session at Allsgood Farm.

Date

First name

Last name

Name you would like to be call

Preferred Pronoun

Phone

Emergency Contact (Name, Relationship, Phone Number, Email)

Would you like to be on our mailing list for course and event notices?

Yes, please.

Not at this time.

Please answer the following questions:

Current regular physical activities

Regular physical activities during childhood

What benefits and/or goals are you looking to achieve

Pregnant or nursing

Concerned with certain movements

Orthopedic problems (Arthritis or any other bone, joint or muscle problems) please explain:

Yes

Medications

Drug Allergies, Other Allergies

Please check the following that apply to you

Currently under the care of a physician or in a rehabilitation program

Have had symptoms of cardiovascular disease, which include and are not limited to pain in chest, neck, jaw, arms, shortness of breath at rest or during mild exertion, dizziness, ankle, edema, heart palpitations, or irregular heart beat

This waiver is meant to support us in caring for the well-being of all who participate in our service, and care for our responsibility in this regard. We acknowledge that some of this language can be off-putting in its legal tone and invite you to connect with us if you have any questions or concerns so we can attend to them.

I acknowledge that I have voluntarily chosen to participate in services offered by Intentionally Wild, Inc. at Allsgood Farm.

I understand that physical activity and other activities and services provided by practitioners of Intentionally Wild, Inc., by their very nature, carry with them certain inherent risk that cannot be eliminated regardless of the care taken to avoid injuries. I understand and acknowledge that there may be dangers,

hazards, and risks inherent in, associated with, or arising out of such activities and services offered by Intentionally Wild Inc. at Allsgood Farm.

I understand that I am not obligated to perform nor participate in any activity that I do not wish to do, and that it is my right to refuse such participation at any time during my training sessions. I give Intentionally Wild, Inc. and the staff of the facilities I receive services in, permission to seek emergency medical services for me should I become injured or ill, with the understanding that I am responsible for any expenses incurred. I understand Intentionally Wild Inc. is not responsible for lost or stolen items. In consideration for being allowed to use the facilities at Allsgood Farm, I hereby voluntarily release, waive, discharge and hold harmless Intentionally Wild Inc., its affiliates, owners, directors, agents, employees, independent contractors, and engaged consultants from and against any and all claims, demands, liabilities, controversies or causes of action, damages, costs and/or expenses of any kind or natures whatsoever, that may hereafter accrue, arising out of or in any manner relating to my use of, or presence at Allsgood Farm, or any activity, exercise, treatment or service performed or undertaken by Intentionally Wild Inc. at Allsgood Farm.

In signing this waiver and release, I acknowledge and represent that I have

carefully read this waiver and release and understand its contents and that I sign this document of my own free will. I assert that my participation is

voluntary and that I assume all risks. I further state that I am at least (18) years of age and fully competent to sign this waiver and release.

I acknowledge and represent that I have carefully read this waiver and that my participation is voluntary and that I assume all risks.

Signature

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