Annual Participant Update Form Logo

  • Annual Participant Update Form

  • Required for all programming- must be completed annually.

  •  - -
  •  - -

  • Legal Parent/Guardian/Caregiver:

    Must be filled out completely if Applicant is under 18 years of age.

  • * 

    *  

    *     

    I      *   consent to and authorize the use and reproduction by Healing Reins of Kentucky, Inc. of any and all photographs, video/audio materials taken of me for the purpose of ongoing studies, educational activities, exhibitions, promotional materials, or for any other use for the benefit of the program. 

    *   Pick a Date*   

  • Liability Release

  • *   * (Participant’s name) would like to participate in Healing Reins of Kentucky, Inc. Program. I acknowledge the risks and the potential for risks of horseback riding, hippotherapy and horse related activities and therapies. However, I feel 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, known and unknown whether existing on the date of the agreement or
    in the future, against Healing Reins of Kentucky, Inc., Blue Moon Stables, LLC, Rolling Hills Equestrian Center, their Board of Directors, Employees, Instructors, Therapists, Aides, Volunteers, Equines, Equine Owners, Equipment and Operating Site for any and all injuries and/or losses I/my son/my daughter/my ward may sustain while participating at Healing Reins of Kentucky, Inc.


    *WARNING Under Kentucky law, a farm animal activity sponsor, farm animal professional, or other person does not have the duty to eliminate all risks of injury of participation in farm animal activities. There are inherent risks of injury that you voluntarily accept if you participate in farm animal activities.

    *   Pick a Date*   

  • Emergency Medical Information:

  • Emergency Contacts:

  • *   *   *   *   *   

    *   *   *   *   *   

  • Medical History:

  • *    Pick a Date*   
    *For Down syndrome an annual medical clearance from a licensed physician that includes a neurological exam that specifically denies any symptoms consistent with atlantoaxial instability (AAI) is required.

    *   *   Controlled?      *    Pick a Date*     

    *   *   *  

    Shunt Present?   *   Pick a Date   

    History of animal abuse:    *   

  • Indicate current or past special needs/concerns/surgeries by checking boxes Y or N. If yes, please comment.

       *   Auditory:      
       *   Visual:         
       *   Tactile Sensation:      
       *   Speech:         
       *   Cardiac:         
       *   Circulatory:         
       *   Integumentary/Skin:      
       *   Digestion:      
       *   Elimination:         
       *   Immunity:         
       *   Pulmonary:      
       *   Neurological:         
       *   Muscular:         
       *   Balance:            
       *   Orthopedic:         
       *   Allergies:         
       *   Learning Disability:   
       *   Cognitive:      
       *   Emotional/Psychological:     
       *   Behavioral:      
       *   Pain:      
       *   Other:      

  • To the best of my knowledge the medical history is true and accurate:

    *   Pick a Date*   

  • Rider Weight Policy:

    Please read

  • Healing Reins of Kentucky, Inc. (HR) will adhere to the following guidelines when making decisions regarding rider weight. Each guideline is in place so that every member of the team (horse, rider and volunteer) may have a safe experience. Horse health, rider’s weight distribution, rider’s ability to dismount without hurting the horse and each volunteer’s ability to safely assist a rider are all very important considerations. Rider will be weighed on-site at intake or first lesson or when deemed
    necessary during a session.

    • Each horse will be evaluated as an individual and assigned a maximum carrying weight.
    • Considerations will be made for age and health/soundness.
    • Each rider will be evaluated as an individual. Considerations will be made for rider’s height, range of motion, balance and ability to dismount independently.
    • Each team will be evaluated to ensure that an appropriate volunteer/instructor is available to complete all emergency procedures including an emergency dismount.
      In general the following rider height to weight ratios will be followed:


    Rider Height Maximum Weight
    Under 5’0” tall 150 lbs.
    5’ to 5’6” tall 175 lbs.
    5’7” to 6’ tall 200 lbs.
    6’1” to 6’5” tall 250 lbs.


    The maximum amount of weight each horse can carry is determines using the following formula:

    • 20% of the horse’s weight minus the weight of tack minus 10 pounds for degrees of unbalanced rider movement. (Unbalanced rider movement is determined through instructor observation while rider is mounted and thorough balance exam while non-mounted.) Other considerations are: observation of equine movement while carrying weight, and veterinary input.
    • Each horse has a maximum number of lessons they may participate in per week. Therefore the number of horses available to carry higher weights may be limited.
    • If, after an evaluation by at least two HR staff members, a rider is determined to be over the weight limit of any available HR horse, the participant has the option to participate in other HR programs, such as therapeutic horsemanship.


    Riders may be asked to weigh-in on Healing Reins scales at any point during their sessions.

  • Healing Reins of Kentucky, Inc.
    PO Box 2027, Henderson, KY 42419

    horsesheal1@gmail.com | www.HealingReinsKY.org

  • Should be Empty: