Participant and Health History Form

Participant's Application & Health History

Participant

Date of Birth

Date

Age

Height

Weight

Gender

MaleFemale

Address

Preferred Phone number

Format: (000) 000-0000.

Email

example@example.com

Alternative phone number

Employer/School

Employer/School Address

Employer/School Phone number

Format: (000) 000-0000.

Parent/ Legal Guardian

Caregivers

Parent/ Legal Guardian Address (if different from above)

Parent/ Legal Guardian Phone number

Format: (000) 000-0000.

How did you hear about the program

Diagnosis

Date of Onset

Date

Please indicate current or past special needs in the following areas:

Rows	Yes	No
Vision
Hearing
Sensation
Communication
Heart
Breathing
Digestion
Elimination
Circulation
Emotional/ Mental Health
Behavioral
Pain
Bone/ Joint
Muscular
Thinking/ Cognition
Allergies

Comments on anything above:

MEDICATIONS (include prescription and over the counter name dose and frequency)

Describe your abilities/difficulties in the following areas (include assistance required or equipment needed):

PHYSICAL FUNCTION (e.g., mobility skills such as transfers, walking, wheelchair use, driving/bus riding)

PHYCHOLOGICAL FUNCTION (e.g., work/ school including grade completed, leisure interests, relationships, family structure, support systems, companion animals, fears/concerns, etc.)

GOALS (i.e., why are you applying for participation? What would you like to accomplish?)

Signature

Date

Photo Release

I DOI DO NOT

consent to and authorize the use and reproduction by (center)

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

(Client, Parent, or Legal Guardian if under 18)

Date

(optional) For demographic data collection only, please check the ethnicity you most identify with:

Emergency Treatment Release Form

Consent Plan and Agreement

(initial) In the event emergency medical aid treatment is required due to illness or injury while being on the property of the agency, I authorize HORSEPOWER Inc. to 1: Secure and retain medical treatment and transportation as needed and 2: Release records upon request to the authorized individual or agency involved in the medical emergency treatment. This authorization includes x-ray surgery hospitalization medication and any treatment procedure deemed "lifesaving" by the physician. This provision will only be evoked if the person(s) below is/ are unable to be reached.

Consent Signature

(If student is under the age of 18 years old this must be signed by a legal guardian)

Date

OR

Non-consent plan

(initial) I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency.

Parent or legal guardian will remain on site at all times during equine assisted activitiesIn the event emergency treatment/aid is required, I wish the following procedure to take place:

Please explain procedure:

Liability Release

(Client's Name)

would like to participate in the HORSEPOWER Inc., program. I acknowledge the risks and potential for risk of horseback riding. However, I feel that the possible benefits to me/my son/my daughter/my ward are greater than the risk assumed. I hereby, intending to be legally bound, for me, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against HORSEPOWER Inc., its Board of Directors, instructors, therapists, aids, volunteers and/or employees for any and all injuries and/or losses I/my son/ my daughter/my ward while participating in HORSEPOWER Inc.

Consent Signature

(If student is under age of 18 years old this must be signed by a legal guardian)

Date

In the event of an emergency, please contact:

Name

Phone

Format: (000) 000-0000.

Name

Phone

Format: (000) 000-0000.

Warning Under North Carolina law, equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting exclusively from the inherent risks of equine activities. Chapter 99E of the North Carolina General Statutes.

4537 Walpole Rd. High Point, NC 27265 - phone (336)931-1424 - fax (336)905-6936