New Participant Application Form

New Participant Application Form
Participant Information:
Full Legal Name*

First NameLast Name
Preferred Name
Birth date *

MonthDayYear
Date
Birthdate *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Phone Number*
We will be using this number to contact you in the case of cancellations Format: (000) 000-0000.
Participant E-mail*
We communicate primarily by email. Please give an email that is regularly checked!
Emergency Contact Name *
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact's Relationship to Participant*

Parent/GuardianSpouseAdult ChildSiblingFriendOther
Height *
Weight *
HTR has a weight limit of 180lbs. If a participant is over 180lbs they cannot ride, but can enroll in Horsemanship lessons
Program Preference *
If the participant is under 4 years old, they are only eligible for Hippotherapy
Is Participant their own legal guardian? *
Parent/Guardian Information
Parent/Guardian Full Name *

First NameLast Name
Parent/Guardian Address (if different than participant)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Phone (if different than participant)
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email (if different than participant)
example@example.com
Health History and Diagnosis:

Please tell us about the participant's past health trends, current health, challenges, and needs in the appropriate sections below. Please also make note of any adaptations the participants requires.
Primary Diagnosis *
Secondary Diagnosis
Cognitive
Physical and Mobility
Communication
Sensory
Emotional/Mental Health
Behavioral
Does the participant have seizures or have a history of seizures?*

YesNo
Does the Participant Have any Indwelling Devices? Please include type and location. *
Does the participant have any allergies, sensitivities, or intolerances to food, the environment, medications etc? If so, please list. *
Please Tell Us About The Participant's Strengths and Goals!
Other - Please tell us anything else we need to know about the participant.
By typing your name in the box below you indicate that the above information is correct to the best of your knowledge. You also understand that participation in any Heartland Therapeutic Riding program also requires completion of our Medical Statement form which must be signed by a physician indicating medical approval of participation. (Parent or Guardian signature required if participant is under 18)
Participant/Guardian Signature*
Date

MonthDayYear
Date
Type full name of person filling out this form*
Relationship to Participant *
Should be Empty: