THERAPY INTAKE

Participant Name*

Date of Birth*

Date

Age

Primary Contact*

Relation

Address*

City, State, Zip*

Phone*

Alternate Phone

Please enter a valid phone number.

Employer / School

Email*

example@example.com

How did you hear about Horse Heritage?

Gender

Due to the safety of the riders, horses and volunteers there is a 1901b weight limit for riders. Riders weighing more than 130lbs must be able to transfer independently. DSHS Caseworker Name and contact phone & email:

Height*

Weight*

DSHS Caseworker Name

DSHS Caseworker Phone

DSHS Caseworker Email

example@example.com

Emergency Contact #1*

Relationship*

Emergency Contact #1 Phone Number*

Please enter a valid phone number.

Emergency Contact #2*

Relationship*

Emergency Contact #2 Phone Number*

Please enter a valid phone number.

Medical conditions requiring special consideration/treatment

Allergies

Current medications & dosage

I consent to and authorize the use and reproduction by Horse Heritage Educational Program 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.

Signature of Participant

Date

Signature of Parent*

Date*

Date

To the Participant or Parent(s)/Legal Guardian(s):

{participantName} would like to participate in the Horse Heritage Therapeutic Riding Program. During the time spent participating in programs using Horse Heritage Educational Program's horses and facilities, he/she will be expected to participate in many activities associated with horsemanship. Precaution and the safety is of the utmost importance. Horse Heritage Educational Program, however, requests your signature in agreement with the following statement. I/We, the undersigned, in full recognition of the possible dangers and hazards inherent in any activity involving horses, do hereby agree to assume all the risks and responsibilities surrounding my child's participation in programs using Horse Heritage Educational Program horses and horse facilities; and further hereby defend, hold harmless, indemnify and release and forever discharge Horse Heritage Educational Program, and its staff members, from and against any and all claims, demands and actions on account of damage to personal property, injury, or death, which may result from my child's participation in programs utilizing Horse Heritage Educational Program's horses and horse facilities, which result from causes beyond the control of and without the fault or negligence of Horse Heritage Educational Program, or its employees/volunteers, during the period of my child's participation in the aforementioned program. All minor participants are required to wear approved equestrian helmets, which Horse Heritage Educational Program will provide for program activities. Under Washington law, an equine activity sponsor or and equine professional shall not be liable for an injury to or death of a participant engaged in an equine activity. RCWA 4.24.530

Participant Signature

Date

Parent/Guardian Signature*

Printed Name of Parent/Guardian*

Date*

Date

Health History*

Do you have any physical complaints or illness a this time?Are your under the care of a physician or practitioner of any sort?Are your on a special diet?Are you taking any type of medication?Do you have diabetes?Do you have asthma?Do you have allergies?Are you current on tetanus?

Other conditions or comments

Do you have issues with Vision? (Glasses or contacts)*

NoYes (comments)

Do you have issues with Hearing? (hearing aids or implants)*

NoYes (comments)

Do you have issues with Sensation? (over or under sensitive)*

NoYes (comments)

Do you have issues with Communication? (use ASL, gestures or have delays)*

NoYes (comments)

Do you have issues with your Heart? (surgeries or implants)*

NoYes (comments)

Do you have issues with your Breathing? (asthma or use oxygen)*

NoYes (comments)

Do you have issues with your Digestion? (gastronomy tube or other)*

NoYes (comments)

Do you have issues with your Elimination? (catheters, colostomy, incontinence)*

NoYes (comments)

Do you have issues with your Circulation? (varicose veins, hemophilia, reduced circulation)*

NoYes (comments)

Do you have issues with your Emotional and Mental Health? (depression or anxiety)*

NoYes (comments)

Do you have issues with your Behavior? (aggression)*

NoYes (comments)

Do you have issues with Pain? (headaches, joint pain)*

NoYes (comments)

Do you have issues with your Bones and Joints? (surgeries, fusions, arthritis)*

NoYes (comments)

Do you have issues with your Muscles? (weakness, low or high tone)*

NoYes (comments)

Do you have Neurological issues? (seizures, ataxias, tremors)*

NoYes (comments)

Do you have Cognitive issues?*

NoYes

Cognitive Age Level*

Physical Function - posture, balance, movement and coordination*

Phycho/Social Function - general attitude and behavior, support system, school dynamics*

Goals - List specific goals for the session (riding, behavioral changes, physical improvements, etc)*

Signature*

Date

PARTICIPANT APPLICATION AND QUESTIONNAIRE

GENERAL INFORMATION

EMERGENCY MEDICAL TREATMENT

PHOTO RELEASE

WAIVER OF LIABILITY