Client Registration Form

Client Registration Form

Therapeutic Riding
Participant Name*
Preferred Name
Birthdate*

MonthDayYear
Date
Age*
Gender*
Race/Ethnicity*
Height*
Weight*
How did you hear about JoyRide?*
Semester of Interest (We will contact you regarding Summer Registration)*

FallSpring
Day & Time Preference*

TuesdayTuesday MorningTuesday AfternoonTuesday EveningWednesdayWednesday MorningWednesday AfternoonWednesday EveningThursdayThursday MorningThursday AfternoonThursday EveningFridayFriday MorningNo preference for day or time
Participant Address
Street Address*
Street Address Line 2
City*
State*
Postal / Zip Code*
Participant Phone
Legal Guardian 1 Full Name*
Legal Guardian 1 Phone*
Legal Guardian 1 Email*
example@example.com
Relationship to Participant*
Legal Guardian 2 Full Name*
Legal Guardian 2 Phone*
Relationship to Participant*
Primary Contact Preferrence*

Legal Guardian 1Legal Guardian 2
Primary Contact Address (if different from above)
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Emergency Contact*
Emergency Contact Primary Phone*
Emergency Contact Relation*
Emergency Contact Relation*
Preferred Medical Facility or nearest*
Primary Physician*
Primary Physician Contact*
Client Diagnosis and Date of Onset*
Any conditions affected by weather (heat, cold, rain), environment (allergies, asthma), or animals (allergies):*
Client Medical History: (surgeries, additional diagnosis, etc.)*
Current Medications (include prescription and OTC name, dose, and frequency)*
Does medication cause photosensitivity?*

YesNo
Physical Function (mobility skills, transfers, walking, wheelchair use, driving, etc.)*
Psycho/Social Function: * (work/school including grade completed, leisure interests, relationships family structure, support systems, companion animals, fears/concerns, etc.)*
Any additional information or behaviors JoyRide staff should be aware of?
Any seizure activity in the last year? If yes, please describe most common type, pre-seizure sensations, frequency, duration, and date of last seizure. What actions would you like us to take if the participant seizes while on the horse?
What are the participant's major goals at JoyRide Center? Equine, life skills, social, etc.*
Is the client interested in participating in competitions? Competitions in which JoyRide participates include Top Hands, Regional Special Olympics, Old 300 Horse Show, and JoyRide’s Trick or Trot.*

YesNo
Contraindications
If any of the conditions below are present, please get in touch with the office for more information.
Atlantoaxial Instabilities – including neuralgic symptoms, Coxa Arthrosis, Cranial Deficits, Heterotopic Ossification/Myositis, Ossificans, Joint Subluxation/Dislocation, Osteoporosis, Neurological, Pathologic Fractures, Spinal Fusion/Fixation, Spinal Instability/Abnormalities, Seizure Disorder, Neurologic Hydrocephalus/shunt, Spina Bifida/Chiari II malformation/Tethered Cord/Hydromyelia, Poor Endurance, Skin Breakdown, Indwelling Catheters, Weight over 240 pounds, Medications – i.e., photosensitivity, Allergies, Blood Pressure Control, Medical/Psychological, Animal Abuse, Physical/Sexual/Emotional Abuse, Dangerous to self or others
Billing Policy
JoyRide appreciates and depends on timely tuition payment. Clients are billed at the beginning of each month for the prior month’s services, and payment is due upon receipt. Bills are emailed to the address you designate on this registration form. Private pay clients will not be charged for classes canceled by JoyRide; however, if you cancel with less than 48 hours’ notice, decline an indoor or unmounted lesson, or do not show up for a lesson/session, you may be billed your class fee. Each student will be allowed one unexcused absence per semester. If clients become two months behind in payments, they risk being withdrawn from the program. Due to generous support, JoyRide has a Tuition Assistance Fund. You can find the application on our website or contact Blake Lewis at Blake@JoyRideCenter.org. Tuition and fees are payable to JoyRide Center by cash, check, or bank draft through QuickBooks invoicing. Payments can be placed in the “Pony Express” box at JoyRide or mailed to JoyRide Center, 29550 Tudor Way Magnolia, TX 77355.

Attendance
When you register for a semester, volunteers, horses, and staff are assigned and look forward to working with you each week. If you are unable to make your class time, please give us at least 48 hours’ notice. If you know of dates you will be absent, please notify the front office or email officemanager@joyridecenter.org. For last-minute cancellations, call JoyRide’s office at 281-356-5900. Clients may be charged regular tuition fees for cancellations or no-shows. Multiple absences within one semester without notice may result in being dropped from the schedule.
Billing Email
example@example.com
Responsible Party Name*
Responsible Party Signature*

Clear
Responsible Party Phone Number
Waivers

Photo Release: To the use and reproduction by JoyRide Center of any and all photographs and any other audio/visual materials taken of me/my son/my daughter/my ward/other family members for promotional printed material, educational activities, exhibitions or for any other use for the benefit of the program. JoyRide policy is that only first names will be used to identify people unless specific permission is given from the parent/client/guardian.
I hereby (check one)*

CONSENTDO NOT CONSENT
Printed Name of Parent/Guardian*
Date*

MonthDayYear
Date
Signature of Parent/Guardian*

Clear
Liability Release

l/my son/my daughter/my ward would like to participate in the JoyRide Center, Inc. program.I

acknowledge the risks and potential risks of horseback riding and working around or near farm animals. However, I feel that the possible benefits to myself/my son/my daughter/my ward are greater than the risk assumed. I hereby, intending to be legally bound, for myself, my heirs, and assigns, executors or administrators, waive and release forever all claims for damages against JoyRide Center, Inc., its Board of Directors, Instructors, Therapists, Aides, Horse Owners, Volunteers and/or Employees for any and all injuries and/or losses l/my son/my daughter/my ward/other family members may sustain while participating in JoyRide programs. WARNING- Under Texas Law (Chapter 87, Civil Practice and Remedies Code), a farm animal professional is not liable for an injury to or the death of a participant in farm animal activities resulting from the inherent risks of farm animal activities.
Printed Name of Parent/Guardian*
Date*

MonthDayYear
Date
Signature of Parent/Guardian*

Clear
CLIENT PACKET ACKNOWLEDGEMENT

Our website has client packets for each program under Client Info and Registration. Please see the "Therapeutic Riding Client Packet."

I have read the client packet, and am aware of JoyRide Center's client policies. I acknowledge I am aware of the following polices: Tardy, Attendance, Billing,
Date*

MonthDayYear
Date
Signature*

Clear
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Privacy practices are found on the JoyRide Center website, oyridecenter.org/info-and-registration OR contact the office for a copy emailed to you.
Date*

MonthDayYear
Date
Signature*

Clear
Application Submission

Please complete all needed information and return to office manager, Blake Lewis, blake@joyridecenter.org.
Printed Name of Parent/Guardian*
Date*

MonthDayYear
Date
Signature of Parent/Guardian*

Clear
Should be Empty:

Client Registration Form

Participant Address