Participant Application Form

Scropton Horse Centre

Home of Scropton Riding for the Disabled

Registered Charity No 1170646
Participant Application Form
If you are under 18 or someone else normally completes your paperwork for you, this form should be completed and signed on your behalf by your parent or legal guardian.

All information will remain confidential for use by centre personnel only.

This application form needs to be completed in one sitting so please make sure you have the following information to hand so that you can complete it in full:
- Personal and contact details
- Details of any previous relevant experience
- If joining as part of a school or training centre, or through a referral from a Council Social Care, Education or Health Department, a contact name/ contact details are needed
- Health Information including details about medical practitioners and medications
- Two emergency contact names & phone numbers
- For anyone signing on behalf of a participant other than a parent, you will need to upload documentation to show that you have the authority to sign on the participants behalf
YOUR DETAILS
First Name*
Middle Name
Last Name*
Preferred Name if different
Date of Birth*

DayMonthYear
Date
Address
First line of address
Second line of address
Town/City
County
Postcode
Email*
example@example.com
Mobile Phone Number
Please enter a valid phone number.
Landline Phone Number
Please enter a valid phone number.
Which activities are you interested in taking part in?

RidingHorse AgilityHorse Care
If you have any previous experience of activities with horses, please tell us the name of the centre where this took place
If you have previously passed any horse related proficiency tests, please list tests and levels achieved

APPLYING THROUGH ANOTHER ORGANISATION
If you are joining as part of a school or training centre, or through a referral from a Council Social Care, Education or Health Department, please fill in the details below.

You do not need to provide this information if you are joining as an independent participant.
School/Department/Centre Name
School/Department/Centre Contact Name
School/Department/Centre Phone Number
Please enter a valid phone number.
School/Department/Centre Email
example@example.com

Please tell us about any diagnosis, disability, difficulty, condition or allergy that may affect the level of support you need to safely participate in activities. Please include any medication taken and potential side effects.
If you are under the care of a doctor for any of the above, please give their name and contact details:
What, if any, conditions or concerns do you have that may need special attention during activities with horses? It is the applicant's responsibility to ensure that we have knowledge of all issues that may pose a problem.
Please provide the name and contact details of a health-care or other professional (eg Physiotherapist, Occupational Therapist, Social Worker or Psychotherapist) who knows you and your health and/or learning needs.
Do you have any specific language needs? (ie nonverbal, BSL, Makaton)
Please provide any other information that would be useful:

EMERGENCY CONTACTS
Please provide details of 2 people who can be contacted in the case of an emergency
Emergency Contact 1
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Emergency contact 2
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.

DECLARATION AND SIGNATURE OF ACCEPTANCE
Please ensure that you read and sign to accept all of the following:

1. I wish to apply as a participant in the centre's activities and confirm that all details given are accurate to the best of my knowledge. I agree that should a centre coach require additional information about me at any time, I will provide what is required. If required, I am willing to obtain reports from a specialist practitioner who is familiar with my condition and understand that I may be required to pay a fee for such a report.

2. I recognise that activities with horses are a risk sport and I voluntarily accept the risks involved. I further understand the need for the participant or carer to take all reasonable precautions. In the absence of any negligence on the part of the centre, I accept that no liability will attach to them.

3. I will immediately inform the centre of any change in my:
- address, email or contact numbers
- medication or in my mental or physical health condition
- changes to my emergency contact details

4. For the welfare of the centre's horses and ponies, all riders will be weighed on the centre's scales at least once per term in their complete riding clothes. This information will be kept confidential on their rider files and only the centre's staff will have access to this information. This information will only be used for the purpose of allocating a suitable horse or pony.

5. Participants need to provide their own riding hat that conforms to valid safety standards (Standards currently include PAS015:1994 or PAS015:1998, ASTM F1163 (2004a), SNELL E2001 or VG1). We have a small number of hats that may be borrowed for initial sessions, but regular participants will need their own hat.

6. If I engage in any behaviour that falls outside the Scropton Behaviour Agreement, this may result in immediate termination of my sessions without notice.
I have read and agree to these terms and conditions*

YesNo
Signature (This must be signed by a parent/legal guardian if the applicant is under 18 years old or where another party is responsible for their legal affairs)*

Clear
Name of signatory*

First NameLast Name
Relationship to applicant (if signing on their behalf)
Position if signed by School/Department/Centre representative
For anyone signing on behalf of a participant other than a parent, please upload documentation to show that you have the authority to sign on the participants behalf

Cancelof
Please let us know the days/times you are looking for lesson. Please also use this space to add any other comments or messages to accompany your application form.
Should be Empty:

Scropton Horse Centre

Home of Scropton Riding for the Disabled

Participant Application Form

YOUR DETAILS

Address

RIDING

If you are applying to ride, please tell us about any previous riding experience:

APPLYING THROUGH ANOTHER ORGANISATION

INFORMATION ABOUT YOU

Speech

Eyesight

Hearing

Mental Health

Learning Disability

Behaviour

Instructions

Walking

EMERGENCY CONTACTS

Emergency Contact 1

Emergency contact 2

CONSENT

Photographs

First Aid

Behaviour Code

Data protection

Communication

Membership Association

DECLARATION AND SIGNATURE OF ACCEPTANCE