PARTICIPANT APPLICATION

PARTICIPANT APPLICATION

Rhythms of Grace, 23625 River Heights Dr, Dallas Center, IA 50063 This information must be updated and submitted annually.
Client Name*

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState Abbrev i.e. IA

Postal / Zip CodeCountry
For the safety of our clients, horses, and volunteers, we adhere to our veterinarian's recommendations for height to weight ratios listed here. If you are outside the height to weight ratios, accommodations can be made at the discretion of the Program Director. We will provide a scale for all participants to weigh at the start of each session and a height tape.
Weight
Height
Gender
Program Participation
Ethnicity
Birthdate

MonthDayYear
Date
Primary Diagnosis
Secondary Diagnosis
Household Income
School/Day Program
County
Referral Method
Mother Name

First NameLast Name
Mother Phone
Please enter a valid phone number.
Mother Email
example@example.com
Father Name

First NameLast Name
Father Phone
Please enter a valid phone number.
Father Email
example@example.com
Guardian/Care Giver

First NameLast Name
Guardian Phone
Please enter a valid phone number.
Guardian Email
example@example.com
Comments

Military Information
Service Status
Service Branch
Military Family
Service Era

Riding Information
During application, you will not complete all these fields. Rhythms of Grace will complete these fields during the initial eval or class. If you have input on likes, dislikes, behavioral status, precautions, etc. feel free to add to these fields.
Saddle
for office use only
Mount
for office use only
Type of Horse Needed
for office use only
Dismount
for office use only
Helmet Size
Direction Following Ability
Precautions
Behavioral Status
Likes
Adaptive Equipment Required
for office use only
Dislikes
Riding Position/posture
for office use only
Ambulatory Status

Paperwork Required
Registration Form

Check this box if you have completed and submitted "The Participant Registration Form and Annual Fee"
RELEASE OF LIABILITY

This section of the page is required to participate in all activities and must be updated annually.

Rhythms of Grace, its officers, members, employees, and agents (including volunteers) will not be responsible for any damages to person, animal or property at the Rhythms of Grace Therapeutic Horsemanship Center or its grounds, nor will they be responsible for any property lost or destroyed. The undersigned Client or parent/guardian hereby releases Rhythms of Grace, its officers, members, employees, and agents from any and all liability and claims of any nature whatsoever, including taking action to control, restrain, or confine the undersigned, for the safety or protection of the undersigned or others and any damages whatsoever (including costs, expenses, and attorney’s fees) that might result from damages, injuries, or losses to their person or property during, or in connection with, or arising out of, any class, lesson, demonstration, show, clinic, event or other function, WHETHER OR NOT SUCH DAMAGES, INJURIES, OR LOSSES RESULT DIRECTLY OR INDIRECTLY FROM THE NEGLIGENT ACT OR OMISSION OR OF ANY INTENTIONAL OR WILLFUL ACT OR TORT OF SUCH RELEASED PARTIES OR OF ANY INVITEE OF ANY RELEASED PARTY.

WARNING: UNDER IOWA LAW (CHAPTER 673, IOWA CODE), AN EQUINE PROFESSIONAL IS NOT LIABLE FOR ANY INJURY TO, OR THE DEATH OF, A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES.

In exchange for the use of property owned/leased by Rhythms of Grace and other valuable consideration, I agree that my use of premises and any animals, facilities, or equipment owned/leased by Rhythms of Grace is at my own risk. I further agree to indemnify and hold harmless Rhythms of Grace, and its respective officers, members, employees, and agents, from any and all suits, actions or claims of any type arising from my use of the premises or participation in an equine activity, or of such use or participation by my guest, whether or not such claims result directly or indirectly from the negligent act or omissions of the indemnified parties or otherwise.
Liability Release

I acknowledge involvement with horses is a high-risk activity. I have read this agreement and fully understand its content.
Required signature of client or parent/guardian of dependent client

Clear
PHOTO RELEASE

For valuable consideration given and which is hereby acknowledged, the undersigned hereby grants to Rhythms of Grace permission to take, or have taken, still and moving photographs and films of the above-named Participant, including television pictures, and consents and authorizes Rhythms of Grace, its advertising agencies, news media, and any other persons interested in Rhythms of Grace and its work, to use and reproduce the photographs, films or pictures, and to circulate and publicize the same by all means, including, without limiting the generality of the foregoing, newspapers, television media, social media, pamphlets, instructional materials, books, grant applications and clinical materials. Please note that your presence or participation in a public event at Rhythms of Grace or event involving Rhythms of Grace constitutes a tacit waiver of this non-consent. Electing the non-consent action will not necessarily prevent a subject from being photographed or filmed at such event by Rhythms of Grace or the general public. With respect to the foregoing matters, no inducements or promises have been made to secure this signature to this release other than the intention of Rhythms of Grace to use, or cause to be used, such photographs, films and pictures for the primary purpose of promoting Rhythms of Grace and its work. Please select "Consent" or "Non-Consent" below.
Photo Release*
NO-SHOW AND CANCELLATION POLICY

1)      Please arrive a few minutes early for your class. This will give you a chance to use the restroom, put on your helmet and be ready to mount on time. It may not be possible to mount a late arrival and if the class has already started, then you will not be able to ride that day.

2)      We will consider you “absent” if you have notified us at least 24 hours in advance. Otherwise, we will consider you a “no-show.”

3)      If you will be absent, please CALL (515)305-7361 and PLEASE LEAVE A VOICEMAIL clearly stating the client’s name, class day, and class time. Texts to this phone number are rarely checked as this is the barn phone.

4)      In the case of an emergency, the client or parent/guardian should call within 24-48 hours after the emergency.

5)      In the case of sudden illness, the client or parent/guardian should call as soon as it is apparent that they will not be able to attend due to illness (at least 2 hours prior to the lesson time).

6)      Excessive absences (3 or more) or no-shows (more than 1) will be subject to losing your class slot and being placed at the end of the waiting list.

7)      Clients who have been awarded a scholarship for the semester and do not follow our cancellation procedures will be subject to forfeiting the scholarship and being ineligible for future scholarships. Scholarship clients may also be subject to a “no-show” fee of $25.

8)      Clients participating under agency funding through the State and do not follow our cancellation procedures will be subject to a “no-show” fee of $25 and will be billed personally.

9)      There will be NO REFUNDS or MAKE-UPS for missed classes unless Rhythms of Grace must cancel due to weather or scheduling conflicts. Payment for the semester is required before the semester begins.

10) If you must withdraw from the semester after it has begun, please contact Rhythms of Grace, (515)305-7361

“No-Show, No-Calls” result in:

Decrease in recruiting and retaining volunteers

Unnecessary tacking and untacking of our horses

Inefficient use of staff and volunteers

Additional Information for Physical/Occupational Therapy Clients

We require a minimum of 2 hours’ notice for the cancellation of a therapy appointment. Cancellations made less than 24 hours in advance may be considered a “no-show” and subject to a cancellation fee of $35.

Cancellations made for reasons that could be rescheduled for another time, such as other therapies, doctor appointments, and vacations must be turned into your therapist a minimum of 2 weeks prior to the absence.
No Show/Cancellation Policy

MonthDayYear
Date
Signature

Clear
PHYSICIAN'S RELEASE

The Physician's Release and Physician's Prescription Form must be completed ANNUALLY PRIOR TO PARTICIPATING. Download these forms on the website https://www.RhythmsOfGraceEquine.org/Programs/PhysiciansForms Once completed and submitted, the date can be entered below by you or Rhythms of Grace.
Physician's Release

MonthDayYear
Date
Signed By

First NameLast Name
Signature

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Submission Date

MonthDayYear
Date
How Satisfied Were You with This Application Process?
Should be Empty:

PARTICIPANT APPLICATION

RELEASE OF LIABILITY

PHOTO RELEASE

NO-SHOW AND CANCELLATION POLICY

PHYSICIAN'S RELEASE