Client Registration Form

Client Registration Form

Therapeutic Riding
Participant Name*
Nickname
Birthdate*

MonthDayYear
Date
Age*
Gender*
Race/Ethnicity*
Height*
Weight*
Semester of Interest (We will contact you regarding Summer Registration)*

FallSpring
Day & Time Preference*

TuesdayTuesday MorningTuesday AfternoonTuesday EveningWednesdayWednesday MorningWednesday AfternoonWednesday EveningThursdayThursday MorningThursday AfternoonThursday EveningFridayFriday MorningFriday Early AfternoonNo preference for day or time
Participant Address
Street Address*
Street Address Line 2
City*
State*
Postal / Zip Code*
Primary Contact*
Primary Contact Phone*
Primary Contact Email*
example@example.com
Relationship to Participant*
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*
Client Diagnosis*
Date of Onset*
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.)*
Does the client participate in any therapies?*

YesNo
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 are the participant's major goals at JoyRide Center?*
What is your availability Tuesday through Friday?*
Is the client interested in participating in competitions?*

YesNo
Billing Policy

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 48hours' 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 will be charged regular tuition fee for cancelations or no shows. Three absences within one semester without notice may result in being dropped from the schedule.
How do you prefer to receive JRC bills? (check one)*

EmailedMailed
Billing Email
example@example.com
Billing Address
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

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