23-24 Prep Registration Form

Client Registration Form

Prep Day Program
Participant Name*
Nickname
Birthdate*

MonthDayYear
Date
Age
Race/Ethnicity
Gender*
Shirt Size*
Preferred Name on Shirt*
Semester of Interest (We will contact you regarding Summer Registration)*

FallSpring
Day Preference*

MondayTuesdayWednesdayThursday
Street Address*
Street Address Line 2*
City*
State*
Postal / Zip Code*
Legal Guardian 1*
Legal Guardian 1 Preferred Email
example@example.com
Legal Guardian 1 Preferred Phone Number *
Please enter a valid phone number.
Legal Guardian 1 Occupation/Name of Company*
Legal Guardian 1 Address (if different from above)
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Legal Guardian 2*
Legal Guardian 2 Preferred Email*
Legal Guardian 2 Preferred Phone Number
Please enter a valid phone number.
Legal Guardian Occupation/Name of Company*
Legal Guardian 2 Address (if different from above)
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Legal Guardian 1 Legal Guardian 2
Preferred Contact*

Legal Guardian 1Legal Guardian 2
Emergency Contact 1*
Emergency Contact 1 Primary Phone*
Emergency Contact 1 Relation*
Emergency Contact 2*
Emergency Contact 2 Primary Phone
Emergency Contact 2 Relation*
Preferred Medical Facility or nearest*
Applicant's Primary Physician Name*
Primary Physician's Phone*
How did you hear about the JRC Prep Day Program?*
Who lives in the household with the participant?
The following person(s) other than legal guardian are authorized to pick up and/or drop off my participant.
1. Name
Cell Phone
Work Phone
Home Phone
Address

Address

Street Address Line 2

CityState

Zip
Relationship

GrandparentRelative Family FriendOther
2 Name (please print)
Cell Phone
Work Phone
Home Phone
Address

Address

Street Address Line 2

CityState

Zip
Relationship

GrandparentRelative Family FriendOther
Name (please print)
Cell Phone
Work Phone
Home Phone
Address

Address

Street Address Line 2

CityState

Zip
Relationship

GrandparentRelative Family FriendOther
4 Name (please print)
Cell Phone
Work Phone
Home Phone
Address

Address

Street Address Line 2

CityState

Zip
Relationship

GrandparentRelative Family FriendOther
Schools/Programs Attended

Day ProgramGroup Care HomePublic SchoolHome SchoolCompetitive EmploymentSupportive LivingPrivate SchoolIndependent Living SituationOther
Please submit most recent ARD & IEP to Prep Manager

Hayley@JoyRideCenter.org
Please include the center/school names and dates attended
Please specify any health diagnosis as well as any developmental disabilities*
Please describe how the applicant communicates and their cognitive age*
Please describe the applicant's social/emotional state most of the time (forexample,withdrawn,hyper verbal, frustrated, sociable, even tempered, etc)*
Any additional information or behaviors JoyRide staff should be aware of?
Please describe the applicant's self help skills (What does someone need to do daily to help the applicant be successful?)*
What is their preferred leisure activity?*
What are the applicant's special interests and strengths?*
Has the applicant ever been involved with any of the following? If yes, please explain in the "Other" portion.
Tobacco

YesOther
Drug Abuse

YesOther
Criminal Activity

YesOther
Sexual Misconduct

YesOther
Please describe activity areas and/or situations that the applicant enjoys*
Please describe activity areas and/or situations that the applicant strongly dislikes*
Please describe what you hope JRC Prep can help accomplish for your participant, as well as any specific goals you have*
Please list any other specialists who are currently treating the applicant
Is the applicant on any regular medications?*

YesNo
If yes, please list below (medication name, side effects that may impact functioning in classes, time administered, and if it is self administered)
Is the applicant allergic to foods, pollens, insect bites, skin contacts, substances, etc?*

YesNo
If yes, please describe allergic reaction and what treatment is usually necessary
Does the applicant carry an EpiPen?*

YesNo
Does the applicant have any dietary restrictions?*

YesNo
If yes, please list dietary restrictions
Has the applicant had more than a brief illness during the past three years?*

YesNo
If yes, when? Please describe the illness
Does the client participate in any therapies?*

YesNo
If yes, what kind of therapies and how often?
Has the client ever had a seizure? If yes, please describe all types, pre seizure symptoms, frequency, duration, and date of last seizure.
What happens during and after the seizure?
If the applicant is prone to, or has had problems with any of the following, please indicate yes.

If yes, please explain in the "other" portion.
Headaches

YesOther
Asthma

YesOther
Heart Trouble

YesOther
Stomach Trouble

YesOther
Diabetes

YesOther
Neurological Problems

YesOther
Emotional Problems

YesOther
Behavioral Problems

YesOther
If there is any further information that you feel should be provided which is a factor and could influence the care, health, and well being of this individual at JoyRide Center, please explain
The information in the above medical history is correct to the best of my knowledge.
Printed name of Parent/Guardian
Signature of Parent/Guardian

Clear
Date*

MonthDayYear
Date
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 blake@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)*
How do you prefer to receive JRC bills? (Check one)*

EmailedMailed
Billing Email
example@example.com
Billing Address
Responsible Party Name
Responsible Party Phone Number
Consenting to this release helps JoyRide Center use photos to promote and fundraise our programs at events and on social media. This also helps prospective clients and parents get a better idea of what a day at JoyRide Center looks like!

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
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 //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
Mechanical Horses & Equine Assisted Learning Waiver

My son/my daughter/my ward is allowed to participate in Equine Assisted Learning and ride indoor, mechanical horses, led by a PATH Certified Riding Instructor, during Prep Day Program.
I hereby (check one)

CONSENTDO NOT CONSENT
Printed Name of Parent/Guardian
Date*

MonthDayYear
Date
Signature of Parent/Guardian*

Clear
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 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.

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, joyridecenter.org/info-and-registration OR contact the office for a copy emailed to you.
Date

MonthDayYear
Date
Signature

Clear
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

Please submit most recent ARD & IEP to Prep Manager

If the applicant is prone to, or has had problems with any of the following, please indicate yes.