Healing Reins Hippotherapy Information

Physical, Occupational Therapy Client Information

Please be as thorough with your answers as possible. The more we understand about you, the better we can serve you! Healing Reins Equine Assisted Services is 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.
Name

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Diagnosis: Primary*
Diagnosis: Secondary
Gender*
Height*
Weight*
Primary Phone (please tell us if it is cell or home )*
Email Address
Street Address*
City*
Zip Code*
School/Institution/Employer Name
Is the Participant a*

MinorAdult with Legal Guardian or CaregiverIndependent AdultVeteran
Are there children in foster care currently residing in the home?

YesNo
Does the participant primarily speak a language other than English?

YesNo
Does the participant's household qualify for Oregon’s free/reduced lunch program?

YesNo
Does the participant's household qualify for SNAP (Supplemental Nutrition Assistance Program)?

YesNo
What is the Participant's racial/ethnic background? (check all that apply)*

Prefer Not To SayAsianMiddle EasternBlack/African AmericanNative American/Alaskan NativeCaucasian/WhitePacific IslanderHispanic or Latino/a/xOther
Other Participant Demographic Data (please select all that apply)

Living on low incomeCurrently experiencing homelessnessLesbian, Gay, Bisexual, or QueerTransgender/Nonbinary/Gender NoncomformingImmigrant or RefugeeChildhood Trauma: foster care placement, incarcerated parents, juvenile justice system, homelessnessReceives special education services as part of a school Individual Education Plan (IEP)
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.)*

YesNo
For minors or adults with legal guardians/caregivers:
Parent or Guardian Name
Phone Number

Area CodePhone Number
Employer
Email Address
Other Parent or Guardian Name
Phone
Employer
Email
Name any caregivers and their phone numbers who may transport or be responsible for the participant
Who can we thank for telling you about us?
Individual Name:
Agency/Organization Name:
Participant Consent & Release Form

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 Healing Reins 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 Equine Assisted Services or presence on the Healing Reins property generally.
I accept and agree to the terms and conditions listed above.*

Agree
Photo & Publicity Release

I DO/ I DO NOT Consent to and authorize the use and reproduction by Healing Reins Equine Assisted Services 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.
I DOI DO NOT
Participant Signature OR Parent/Guardian Electronic Signature if participant is a minor or has a legal guardian *
Participant Consent & Release of Information

Healing Reins is required to have a copy of each participants physicians release. If the participant has Down Syndrome Healing Reins is required to have a copy of the AAI release.
I hereby authorize the treating therapist to release to Healing Reins staff my child's pertinent medical information including, but not limited to, the Hippotherapy Physician Release form for the purpose of coordinating care of my child. This permission will expire 12 months from the date of signature, unless otherwise revoked in writing by an authorized adult/caregiver. *
Date Signed *

MonthDayYear
Emergency Contact Information
Emergency Contact 1*
Relationship to Participant*
Phone Number*
Emergency Contact 2
Relationship to Participant
Phone Number
Electronic Signature*
Date:*

MonthDayYear
Should be Empty: