Lesson Program Application – Flying Manes Therapeutic Riding

PARTICIPANT INFORMATION

Participant Name *

First

Last

Date of Birth *//

Age *

Gender *

Female
Male

Weight (lbs) *

Height (feet, inches) *

Primary/Secondary Diagnosis *

First Parent/Guardian Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Second Parent/Guardian Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

School or Institution presently attending

School Phone

School Address

Address Line 1

Address Line 2

City

State

Zip Code

LIABILITY RELEASE

Participant's Name *

First

Last

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.

Signature *

If applicant is under 18 years of age, parent/guardian signature is required.

TESTING RELEASE

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.

Participant's Name *

First

Last

Signature *

If participant is under 18 years of age, parent/guardian signature is required.

MEDIA RELEASE

I hereby consent to and authorize
I do not consent to, nor do I authorize

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.

Signature *

If participant is under 18 years of age, parent/guardian signature is required.

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

Primary Care Physician's Name *

First

Last

Primary Care Physician's Phone *

Please upload the participant's Medical History/Physician's Statement form

This form was emailed to you together with the link to this online application page.

Does the participant see a mental health professional? *

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) *

First

Last

Relationship *

Phone *

Name (Emergency Contact 2) *

First

Last

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.

Consent Signature *

If participant is under 18 years of age, parent/guardian signature is required.

NON-CONSENT PLAN

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):

Signature

If participant is under 18 years of age, parent/guardian signature is required.

PARTICIPANT QUESTIONNAIRE

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? *

Does the participant receive occupational therapy? *

Does participant have an IEP? *

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?

Signature *

If participant is under 18 years of age, parent/guardian signature is required.