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.
Participant Information
Participant Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
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Age
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Gender
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Height
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Weight
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Phone Number:
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-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
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example@example.com
First Responder Occupation:
Status:
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Currently Employed
Retired
Branch of the military:
Were you deployed or in active duty after 9/10/2001
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Status:
Active Duty
Veteran
I am interested in the following group experiences:
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Combat Veterans
Female Veteran Groups
Couples
Family
Peer Support
Peer Team Building
Equine Assisted Mental Health Individual or Family
No Group Preference
Community Outreach LEADERS Session
First Responders
Describe your experience with horses:
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Health History
Please list all medication (including medical marijuana)
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Please note any health concerns, assistive devices, allergies and EpiPen or inhaler used:
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Please list any goals you have for participation
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Will Family Members be joining you in the Session?:
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Yes
No
If yes, please list name, age, and relation.
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Participant Electronic Signature:
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Date:
*
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Month
-
Day
Year
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Participant-Family 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 Equine Assisted Services, an Oregon non-profit corporation, I authorize Healing Reins 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 Healing Reins 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 Healing Reins 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, Healing Reins Equine Assisted Services, 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 Healing Reins program or presence on the FRF property generally.
I accept and agree to the terms and conditions listed above for myself and family members joining me
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Agree
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
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I DO
I DO NOT
Participant Electronic Signature
*
Date:
*
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Month
-
Day
Year
Date Picker Icon
Submit
Name
First Name
Last Name
Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Age
Weight
Height
Please note any health concerns, allergies and EpiPen or inhaler used:
*
Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Age
Weight
Height
Please note any health concerns, allergies and EpiPen or inhaler used:
Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Age
Weight
Height
Please note any health concerns, allergies and EpiPen or inhaler used:
Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Age
Weight
Height
Please note any health concerns, allergies and EpiPen or inhaler used:
Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Age
Weight
Height
Please note any health concerns, allergies and EpiPen or inhaler used:
Family 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.
*
Agree
Family 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
I DO NOT
Parent/Legal Guardian Electronic Signature
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Date:
*
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Month
-
Day
Year
Date
Submit
Should be Empty: