ECL Therapeutic Horseback Riding Participant Application

Equine Center for Learning

Therapeutic Horseback Riding Participant Application
Participant Information
Participant's Legal Name

First NameLast Name
Participant's Preferred Name or Nickname:

First NameLast Name
Birth Date

MonthDayYear
Grade
School
Participant's Height
Participant's Weight
Sex

MaleFemale
Pronouns:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Does the student...

	Yes	No
Have a history of seizures?
Follow simple directions?
Have speech or language difficulties?
Have a fear of animals/horses?
Walk independently?
Have limited range of motion?
Have decreased strength/endurance?
Have poor balance (sitting/standing)?
Have problems with gross motor skills?
Have problems with fine motor skills?
Have altered sensation?
Have heart/circulation problems?
Have digestion/elimination problems?
Have bone/joint problems?
Have allergies or breathing problems?
Have emotional/behavioral problems?
Have had any major surgeries?
Have a history of concussion/serious head injury?
Have tactile sensitivities?

If you selected yes to any of the above choices above please elaborate below.
Please mark any of the following that have been recent or past issues. These items will not be used to prevent anyone from participating; rather, they are to assist us in best meeting your needs.

Mental Health TherapyLegal problemsGrief/LossTraumaSpecial assistance at schoolSubstance abuseFamily problems
If you selected any of the above options please provide specific commentary that is important for the instructor to know below.
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Student Goals
What would you like to accomplish in our program?
Additional information that would be helpful in class selection and lesson planning:
Please list any accommodations/concerns the instructors should be aware of:
Has the participant had any prior experience with horseback riding?

YesNo
If you selected yes, please elaborate on the horseback riding experience below.
Liability Release Agreement

I agree to the following agreement with the Equine Center for Learning (ECL) and the Lansing School District, a Michigan non-profit organization, (hereafter referred to as "Center"), as a condition for allowing me, and and the persons identified below, to enter the Center's premises and surroudning land, to be near horses, participate in equine-assisted activities, ride the horse, work near the horses, participate in hay rides, handle horses, use equipment, work with staff and volunteers, and/or recieve information or guidance in riding, grooming, or handling the horses (these activities will hereafter be referred to in this document as "The Actvities").

IT IS HEREBY AGREED AS FOLLOWS:

I/we are aware and acknowledge the inherent dangers, hazards and risks, associated with equine activites. I/we understand that the inherent risks of the equine activities mean those dangerous conditions which are an integral part of the equine activities include but not limited to:

1. The propensity of any equine to behave in ways that may result in injury, harm or even death to persons on or around them and/or damage to property in their vicinity.

2. The unpredictability of an equine's reaction to such things as sounds, sudden movement and unfamiliar objects persons or other animals.

3. The equine's response to certain hazards such as surface and sub-surface objects.

4. Collisions with other equines, animals, people, and objects.

The potential of any participant to act in a neligent manner than may contribute to injury to the participant or others, such as failing to maintain control over the equine or to act within his/her ability. I/we assume these risks and accept the consequences involved in the participation of the participant registered on this form. I/we will consult with the instructor of the Equine Center for Learning (ECL) for advice in circumstances where safe practices are in doubt.

Warning: Under the Michigan equine liability act, an equine professional is not liable for an injury to or the death of a participant in an equine activity resulting from an inherent risk of the equine activity.

I/we have read and fully understand the content of this release of liability and agree to comply with the intent to hold harmless or to indemnity the Equine Center for Learning (ECL), the Lansing School District, its' staff, volunteers or any other individuals and/or organizations involved, from any liabillity or injury that may result from participation in this program.

I/we understand that the Equine Center for Learning (ECL), always recommends that I/we seek the advice of a physician, as many of The Activities pose special phsycial risks to the participant and even to the volunteer. I/we acknowledge that it is my/our responsibility to make the Equine Center for Learning (ECL), aware of any conditions that may affect my ability to handle, ride and/or be near to an equine.

I/we have received informaiton on the signs, symptoms and consequences of concussions in accordance with Public Acts 342 and 343 of 2012. By signing below, I/we acknowledge that I/we have read, fully understand, and sign voluntarily as my/our own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully comptent; and if not eighteen (18) then my parents/guardians sign for me, and I/we execute this agreement for full, adequeate and complete consideration fully intending to be bound by the same.
Student's Name:

First NameLast Name
Student's Initals
Parent/Guardian Name (if student is under 18):

First NameLast Name
Parent/Guardian Initials
Authorization for Medical Treatment

I/we, give my/our consent, in case of a medical emergency, to authorize the Equine Center for Learning staff to provide such medical assistance as they determine necessary. I/we authorize any licensed physician and/or medical facility to provide medical, surgical care and/or hospitalization for the participant, including anesthetic, which medical professionals determine to be necessary or advisable, pending receipt of a specific consent from me/us.I/we, DO NOT give consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being present on the property of the agency (ECL).
Photo and Video Release - The Lansing School District and the Equine Center for Learning occasionally uses photographs and/or video of the students for promotional purposes through broadcast, print, or social media. These photos may be taken during an event or a class that the participant has enrolled in.

YES, it is alright for the Lansing School District to use CAMP photos and/or video of my student for promotional purposed through broadcast, print, and/or social media.NO, it is NOT alright for the Lansing School District to use CAMP photos and/or video of my student for promotional purposed through broadcast, print, and/or social media.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Student Signature

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Date

MonthDayYear
Date
Parent/Guardian Signature (If student is under 18)

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Equine Center for Learning

Participant Information

Student Goals