HORSEPOWER Participant's Application & Health History

HORSEPOWER
Participant's Application & Health History
Participant*
Date of Birth

MonthDayYear
Date
Age
Height*
Weight*
Gender

MaleFemale
Address
Preferred Phone
Email
example@example.com
Alternative #
Employer/School
Employer/School Address
Employer/School Phone
Parent/Legal Guardian Name
Parent/Legal Guardian Address (if different from above)
Parent/Legal Guardian Phone*
Caregivers
Please list Name and Phone #
How did you hear about the program?
Health History
Diagnosis*
Date of Onset

MonthDayYear
Date

Please indicate current or past special needs in the following areas:*

	Yes	no
Vision
Hearing
Sensation
Communication
Heart
Breathing
Digestion
Elimination
Circulation
Emotional/Mental health
Behavioral
Pain
Bone/Joint
Muscular
Thinking/Cognition
Allergies

Comments
ex. (Allergies: seasonal)
MEDICATIONS (include prescription and over the counter, name, dose. and frequency)
Describe your abilities/difficulties in the following areas (include assistance required or equipment needed):
PHYSICAL FUNCTION (e.g., mobility skills such as transfers, walking, wheelchair use, driving/bus riding)
PHYCHOLOGICAL FUNCTION (e.g., work/school including grade completed. leisure interests, relationships, family structure, support systems, companion animals, fears/concems, etc.)
GOALS (i.e., why are you applying for participation? What would you like to accomplish?
Signature*

Clear
(If student is under age of 18 years old this must be signed by a legal guardian)
Date

MonthDayYear
Date
Photo Release*

I doI do NOT
consent to and authorize the use and reproduction by (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.
(center)
Signature*

Clear
(If student is under age of 18 years old this must be signed by a legal guardian)
Date

MonthDayYear
Date
(Optional) For demographic data collection only, please check the ethnicity you most identify with:
Ethnicity

CaucasianAfrican AmericanHispanicMiddle EasternAsianMulti- RacialOther
other:
Emergency Treatment Release Form

Consent Plan and Agreement
(initial) In the event emergency medical aid/treatment is required due to illness or injury while being on the of the agency. I authorize HORSEPOWER Inc. to 1: Secure and retain medical treatment and transportation and 2: Release records upon request to the authorized individual or agency involved in the medical emergency This authorization includes x ray, surgery. hospitalization, medication, and any treatment procedure deemed by the physician. This provision will only be evoked if the person(s) below is/are unable to be reached.*
Please initial
Consent Signature*

Clear
(If student is under age of 18 years old this must be signed by a legal guardian)
Date

MonthDayYear
Date
OR

Non-Consent plan
(initial) I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the of receiving services or while being on the property of the agency.
Non-Consent plan

Parent or guardian will remain on site at all times during equine assisted activitiesIn the event emergency treatment/aid is required, I wish the following procedure to take place
Procedure:
Liability Release
(Client's Name) would like to participate in the HORSEPOWER Inc. program. I acknowledge the risks and potential for risk of horseback riding. However, I feel that the possible benefits to me/my son/my daughter/my ward are greater than the risk assumed. I hereby, intending to be legally bound, for me, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against HORSEPOWER Inc., its Board of Directors, instructors, therapists, aids, volunteers and/or employees for any and all injuries and/or losses I/my son/ my daughter/my ward while in HORSEPOWER Inc.*
Enter Client's Name
Consent Signature*

Clear
(If student is under age of 18 years old this must be signed by a legal guardian)
Date

MonthDayYear
Date
In the event of an Emergency, please contact:
Emergency contact name:First Name* Last Name* Phone: Phone Number*
Emergency contact name:First Name Last Name Phone: Phone Number
Warning Under North Carolina law, equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting exclusively from the inherent risks of equine activities. Chapter 99E of the North Carolina General Statutes.

4537 Walpole Rd. High Point, NC 27265 - phone (336)931-1424 - fax (336)905-6936
* By clicking "Submit" I agree my electronic signature and initials have the same force and effect as my written signature or initial.
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform