Heroes Horsemanship Equine Assisted Learning Application
Please be as thorough with your answers as possible. The more we understand about you, the better we can serve you! As a nonprofit organization, we rely heavily of grants that require us to report demographic information about our participants. Thank you for providing this information so that we can continue to provide our high-quality programs at the lowest cost possible. All information is protected by our confidentiality policy.
Branch of the military
Date of Birth
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Is the Participant a
Adult with Legal Guardian or Caregiver
Are there children in foster care currently residing in the home?
Does the participant speak a language other than English at home?
Does the participant's household qualify for Oregon’s free/reduced lunch program?
What is the Participant's racial/ethnic background?
Native American/Alaskan Native
Is the participant considered part of a vulnerable, underserved or underrepresented population? (Vulnerable and underserved populations generally include the economically disadvantaged, experiencing homelessness, low-income, racial and ethnic minorities, members of the LGBTQ+ community, youth with trauma related adverse childhood experiences, children with incarcerated parents, or individuals experiencing physical or mental challenges.)
Describe your experience with horses:
Please list all medication (including medical marijuana)
Please note any allergies and if EpiPen or inhaler is used
Please check health conditions that appy:
Visual - learns by doing
Auditory – learns by hearing
Kinesthetic – learns by doing
Please list any goals you have for participation
Participant Electronic Signature:
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Participant Medical Consent & Liability
CONSENT FOR EMERGENCY MEDICAL TREATMENT: In the event of an emergency, if medical aid/treatment is required due to illness or injury while participating in the services of, or while being on the property of, Healing Reins Therapeutic Riding Center (“HRTRC”), an Oregon non-profit corporation, I authorize HRTRC to secure and retain medical treatment and/or transportation if needed. This authorization includes any treatment deemed necessary by a treating health care professional and includes, but is not limited to, x-ray, surgery, hospitalization, and medication. In addition, I authorize HRTRC to release my/my child/my ward’s records to any individual involved in medical treatment and/or necessary transportation.LIABILITY RELEASE: Under Oregon Law, an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of participating in equine activities, pursuant to section 30.691, Oregon Revised Statutes. I would like to participate in HRTRC’s program. I acknowledge the risks and potential for risks in riding and working with horses. However, I feel that the possible benefits to myself/my child/my ward are greater than the risks assumed. Intending to be legally bound, for myself and my heirs, assigns and legal representatives, I hereby forever waive and release any and all claims, whenever arising, against Faith Run Farms, LLC (“FRF”) an Oregon limited liability company, HRTRC, and their respective directors, officers, members, employees, agents and representatives arising from, or relating in any way to my/my child’s/my ward’s participation in any HRTRC program or presence on the FRF property generally.
I accept and agree to the terms and conditions listed above.
Photo & Publicity Release
I DO/ I DO NOT Consent to and authorize the use and reproduction by Healing Reins Therapeutic Riding Center of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
Choose one option
I DO NOT
Participant Electronic Signature
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I am interested in the following group experiences:
Female Veteran Groups
Peer Team Building
Equine Assisted Mental Health Individual or Family
Should be Empty: