TROT Horses Helping Heroes

TROT - Horses Helping Heroes Participant Application
Applicant's Personal Information
Participant's Name*

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Height:
Weight:
E-mail*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What class season are you interested in?

SpringSummerFall
How did you hear about us?

Employer
Current Occupation
Marital Status

SingleMarriedSeparatedDivorced
Race (optional)
Gender (optional)
Monthly Income (optional)
Do you have a service or therapy animal?

YesNo

Authorization For Emergency Medical Treatment Form
Participant's Name

First NameLast Name
DOB

MonthDayYear
Date
Age
Years
Weight
Lbs
Height
Feet/Inches
Preferred Phone Number
Preferred

HomeWorkMobile
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's Name

First NameLast Name
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's Phone Number
Physician's Fax
Health Insurance Company
Policy #
Allergies to Medications:
Current Medications:
In the event of an emergency, contact:
Name:

First NameLast Name
Relation:
Phone Number
Caretaker (if applicable):

First NameLast Name
Phone Number
In the event of an emergency where medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the TROT premises, I authorize TROT to:
1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to be authorized individual or agency involved in the medical emergency treatment.
This authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedure deemed “life-saving” by physician. This provision will only be invoked if the person(s) above are unable to be reached.

Horses Helping Heroes General
Policies and General Safety Rules
Thank you for your interest in the Horses Helping Heroes program!   Please read our general policies and safety rules below and check and initial each box to indicate your compliance. We look forward to sharing our love of learning and of horses with you!

Policies

1.     While we do utilize our indoor classroom, please keep in mind our classes mostly take place outdoors. Make sure you are prepared for the possibilities of dusty air quality, wind, heat, and chilly weather. General Safety Rules must always be considered regarding proper attire.

2.     To ensure we can provide proper accommodations, please inform us of any health conditions or devices necessary to help you enjoy our program. All medical information is kept confidential under HIPPA compliance.

3.     General Safety Rules will be enforced in every class session and are clearly posted at our facility. TROT instructors or administrators have the right to dismiss any participant in the event of participant unsafe practices or behavior.

4.     We take great care in ensuring the safety of our participants, however there is always the risk of injury when working with horses. Therapeutic Riding of Tri-Cities is a ‘Ride at your own risk’ facility and any injury incurred on our premises is the responsibility of the participant. Medical coverage or cost assistance is not available through our program.
I have read and agree to TROT's policies.
Safety Rules

Please take care to follow these rules and any other instruction given during our classes to ensure your personal safety.

1. Always follow directions from TROT staff.
2. All participants must wear ASTM-approved riding helmets when either near or on horses; TROT can supply these helmets as needed.
3. Do wear required attire:

a. Closed toed shoes (preferably boots)
b. Long Pants
c. Tied back long hair
d. No Jewelry (such as rings, bracelets, large earrings, or big/long necklaces, perfumes)
e. No baggy clothing
f. No scented products (i.e. body spray, perfumes, etc.)

2. Do not chew gum.
3. Cell phones or personal electronic devices are not permitted while participating in our classes.
4. Do not run.
5. Do not yell
6. Do not feed the horses unless under the permission/supervision of an instructor.
I have read and agree to TROT's general safety rules.
Why Horses?

Horses, with a unique sensitivity to people’s feelings, react to subtle changes in their environment by responding to and reflecting emotions. The bond between horse and human is both well-researched and well-documented. Because horses are large and powerful animals, they can often feel intimidating to people who have little experience with them. The Horses Helping Heroes program, however, is designed to help people overcome that initial intimidation to develop a deep, lasting bond with the animal. Horses, alert and exceptional at reading and responding to non-verbal cues, are also adept at mirroring emotions; furthermore, they are sensitive animals that immediately empathize with humans who regularly care for them. The act of repeatedly grooming a horse, therefore, is emotionally soothing and fosters a loving and trustworthy relationship between human and horse.

What is the Horses Helping Heroes Program?

This six-week program alternates groundwork with mounted segments in each class. Participants learn basic equine communication and body language, as well as grooming, tacking, safe leading techniques, mounting, dismounting, and various riding aids and techniques.
Participant Release, Waiver of Liability, Assumption of Risks and Indemnity Agreement
In consideration of being permitted to participate in the Therapeutic Riding of Tri Cities, Instructional Riding for Special Needs persons herein by this reference (“Event”) on the premises located at 104 E. 41st. Place, Kennewick WA., (“Premises”), the student/volunteer named below, individually and on behalf of any marital community, heirs, children, successors and assigns (collectively “Releasor”) knowingly and voluntarily agrees to release, defend, indemnify and hold Therapeutic Riding of Tri Cities (TROT), a Washington Non-Profit Corporation, harmless, including without limitation, its employees, managers, directors, officers, agents, attorneys, successors and assigns (collectively “Releasee”) as follows:

1.         Prior to participating in the Event, Releasor shall inspect the Premises and the Event and inspect all related equipment to be used. If Releasor believes any of the foregoing are unsafe, Releasor shall immediately advise TROT management of such condition, and refuse to participate in the Event. If Releasor feels in any reasonable way during the Event that anything or any participant becomes unsafe, Releasor will immediately take all precautions to avoid all such dangers and REFUSE TO FURTHER PARTICIPATE AND ASSIST TO KEEP ANY PARTICIPANT OUT OF HARMS WAY.

2.         Releasor fully understands and acknowledges the risks associated with participating in the Event at the Premises and fully and unconditionally assumes and accepts each such risk. Releasor hereby stipulates that Releasee has read the warning and understands the dangers of being around horses and children with spontaneous and possibly angry or violent tendencies where serious injury or death may occur.

3.         Releasor knowingly and voluntarily agrees to defend, indemnify and hold Releasee harmless for any and all losses and/or damages to Releasor or third parties in the Event and third parties not associated with the Event, including, without limitation, any injury, disability, paralysis or death, regardless of cause and however caused and whether caused in whole or in part by the negligence of the Releasee named below.

4.         Releasor hereby expressly acknowledges that any injuries received may be compounded or increased by negligent or delayed rescue or emergency operations over which Releasee may or may not have control and further assumes any and all risks associated with any such delayed rescue or emergency operations.

5.         Releasor further expressly agrees that this Release, is intended to be as broad and as inclusive as permitted by the laws of Washington State, and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

6.         This release, waiver of liability, assumption of risk and indemnity agreement has legal effect and releasor is hereby informed of the right to seek independent legal review of this instrument prior to signing. If releasor fails to seek the advice of an attorney prior to signing this instrument, releasor shall be deemed to have knowingly and voluntarily waived any and all rights to seek legal review of this instrument, and any claim or cause of action that arises out of or is related to the participation of the event at the premises. If, despite this release, the releasor makes a claim against any of the covered parties that make up releasee, releasor shall reimburse releasee for any and all costs and expenses, including attorney’s fees, that releasee has paid in order to hold releasee harmless.

RELEASOR HAS READ THIS RELEASE, WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTANDS ITS TERMS, UNDERSTANDS THAT RELEASOR HAS FORFEITED SUBSTANTIAL RIGHTS BY SIGNING THIS RELEASE, WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, HAS SIGNED THIS INSTRUMENT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE OF ANY KIND

BEING MADE TO RELEASOR, INTENDS THE SIGNATURE BELOW TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY, INCLUDING ANY GROSS NEGLIGENCE OF RELEASEE, AND KNOWINGLY AND VOLUNTARILY WAIVES ANY AND ALL CAUSES OF ACTION AGAINST RELEASEE TO THE GREATEST EXTENT ALLOWED BY LAW.

Premises located at: 104 E. 41st Place, Kennewick, WA 99337
Signature of Releasor
Print Name:
Date

MonthDayYear
Photo Release
For valuable consideration, acknowledged as received, I hereby grant permission and consent to Therapeutic Riding of Tri-Cities (TROT), its successors, licensees and assigns, to take still and moving photographs, digital images and films, including television footage (collectively “Work”) of me:

I hereby further grant and assign to TROT the unrestricted and unbridled consent and authority, without further consent, inspection or approval, to use and reproduce the Work and to circulate, publish and publicize the Work by all means, including, without limitation all forms of media in newspapers, television, printed media, brochures, pamphlets, instructional materials, books, electronic media, website, social media (i.e., Instagram, Facebook, Twitter, Etc.) and clinical matters, and to alter the same without restriction, and without my inspection or approval. I hereby release TROT and its legal representatives and/or assigns from all claims relating to such Work.

With regards to the foregoing material, no inducement or promises have been made to me to secure my signature to this Release other than the intention of TROT to use or have used such Work for the primary purpose of promoting and aiding TROT and its purposes.
NO, I do not give my consent to this ReleaseYES, I do give my consent to this Release
Signature
Print Name:
Date

MonthDayYear
I have read the above waiver and I agree to its conditions and terms:*
Parent/Guardian Signature (if Releasor is a minor):
Type Name of Parent/Guardian
Date

MonthDayYear
Date
Should be Empty:

TROT - Horses Helping Heroes Participant Application

Applicant's Personal Information

Experience & Goals