Intake Assessment Form

SMARTcert Canada Practitioner students participate in 2 training dates, each of which require 5 horses that can be assessed and massaged. The participation of a horse that you own is greatly appreciated, and any information that you can provide with as much detail will help the instructor & student create the most informative learning experience possible.

You are welcome to attend if you would like (not required; handlers are available), or a report can be created and sent to you *by the student – an informal addition to your horse’s health records*.

Name of SMARTcert Canada Student working with your horse (First & Last)(required)

Owner's Name (First & Last)(required)

Email(required)

Phone Number(required)

Horse's Name(required)

Horse's Age(required)

Horse Breed(required)

Discipline(s) that this horse performs and # of times/week that this horse is ridden(required)

Describe this horse's competitive season

Is your horse in a regular massage/chiro or other bodywork program? Please provide details.

Check the box to agree to the following:

I AM ALLOWING EQUI-SMART, SMARTCERT CANADA, AND ALL PERSONS CORRELATED TO THE COMPANY (INCLUDING STUDENTS) TO ASSESS, TREAT, AND CUSTOMIZE A PROGRAM FOR MY HORSE. I AGREE TO HOLD THEM HARMLESS FOR ALL INCIDENTS THAT MAY OCCUR DURING THE TIME THAT EQUI-SMART IS PRESENT, OR DURING THE TIME THAT I AM CARRYING OUT THE ASSIGNED PROGRAM(required)

I AGREE TO SEEK VETERINARIAN ADVICE FOR ANY APPLICABLE CIRCUMSTANCES OR SCENARIOS, AND UNDERSTAND THAT EQUI-SMART'S ADVICE AND SERVICES DO NOT REPLACE VETERINARY CARE AND ARE NOT CONFIRMED DIAGNOSES OF ANY INJURIES OR CONDITIONS(required)

I AGREE TO ALLOW EQUI-SMART TO TAKE PICTURES AND VIDEOS OF MY HORSE, PRIMARILY AS A METHOD OF MAINTAINING RECORDS, BUT I ALSO UNDERSTAND THAT THE PICTURES AND VIDEOS MAY BE SHARED FOR TRAINING PURPOSES WITH OTHER MASSAGE THERAPISTS OR STUDENTS(required)

PLEASE WRITE YOUR FIRST AND LAST NAME BELOW, SERVING AS YOUR ELECTRONIC SIGNATURE FOR THE ABOVE WAIVER AND FORM(required)

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