PARTICIPANT INFORMATION Date of Birth * MM 1 2 3 4 5 6 7 8 9 10 11 12 / DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / YYYY 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Age * Weight (lbs) * Height (feet, inches) * Primary/Secondary Diagnosis * First Parent/Guardian Name * Email * Phone * Second Parent/Guardian Name * Email * Phone * School or Institution presently attending School Phone LIABILITY RELEASE Participant's Name *
would like to participate in the Flying Manes Therapeutic Riding, Inc. Program. I acknowledge the risks and potential for risks of horseback riding and related equine activities, including grievous bodily harm. However, I feel that the possible benefits to myself/my child/my ward are greater than the risk assumed. I hereby, intending to be legally bound for myself, my heirs and assigns, executors, and administrators, waive and release forever all claims against Flying Manes Therapeutic Riding, Inc., its Board of Directors, Instructors, Therapists, Aides, Volunteers, and/or Employees for any and all injuries, losses and/or costs I/my child/my ward may sustain while participating in the Program from causes including but not limited to the negligence of these released parties or any acts of third parties.
The undersigned acknowledges that he/she has read this Registration and Release Form in its entirety; that he/she understands the terms of this release and has signed this release voluntarily and with full knowledge of the effects thereof.
I have read the letter to prospective Flying Manes Therapeutic Riding participants, parents, and/or teachers. I understand the importance of administering an intake assessment for new participants. I give permission for the below named individual to be tested by Flying Manes Therapeutic Riding, Inc.
the use and reproduction of any and all photographs and other audiovisual materials taken of me/participant by Flying Manes Therapeutic Riding, Inc. for promotional printed material, educational activities, exhibitions, or for any other use for the benefit of the program.
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT Primary Care Physician's Name * Primary Care Physician's Phone * Does the participant see a mental health professional? * Yes No Current allergies, medications, and health concerns /recent surgeries or medical developments: * Health Insurance Provider Health Insurance Policy Number Preferred Medical Facility Emergency Contacts Name (Emergency Contact 1) * Relationship * Phone * Name (Emergency Contact 2) * Relationship * Phone * CONSENT PLAN
In the event that emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the host facility (Riverdale Stables at 6351 Broadway, Bronx, NY 10471), I authorize FLYING MANES THERAPEUTIC RIDING, INC. to:
1. Secure and retain medical treatment and transportation, if needed.
2. Release participant 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 physician. This provision will only be invoked if the emergency contact listed cannot be reached.
I do not give consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the host facility (Riverdale Stables, 6351 Broadway, Bronx, NY 10471). In the event emergency treatment/aid is required I wish the following procedures to take place (please provide details below):
It is helpful for the staff at Flying Manes Therapeutic Riding to know a participant's background, goals, and interests, and understand his or her current status prior to developing a objectives and goals. Please respond to the following questions.
Can the participant sit independently? * Please provide details: Can the participant stand independently? * Please provide details: Can the participant walk independently? * Please provide details (e.g. mobility aids used): Is any adapted equipment used? * Please describe the participant's current posture, balance, movement, and coordination: * Does the participant receive physical therapy? * Yes No Does the participant receive occupational therapy? * Yes No Does participant have an IEP? * Yes No Please describe the participant's general attitude & behavior: * Please describe any perceptual/ balance problems: * Please describe the current level of the participant's cognitive abilities (age level, multi-step directions): * Is the participant verbal? * Please describe his/her communication style and challenges (verbal, sign, PEC): * If nonverbal, how are important messages (bathroom break, hunger, thirst, pain, fear) communicated? Are there any trigger words/actions we should be aware of? * What are the participant's goals for his/her riding sessions (riding skills, behavioral changes, physical improvements, paying attention)? Please be specific: * Are there any special considerations we should be aware of (health, precautions, medications, etc)? Please describe the participant's attitude toward/experience with animals: * Please describe any previous horseback riding experience: * Please list other areas of interest or hobbies, sports, recreational activities: * Do you have any other suggestions or comments for us? Who would accompany the participant to Flying Manes therapeutic riding classes? * How did you hear about our program?