Participant Application for Riding Warriors at SAMS RANCH

Date of Application:*

Date

Participant's Name:*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth:*

Date

Gender:*

MaleFemale

Height:*

Weight:*

Phone Number:*

Email Address:*

example@example.com

Emergency Contact:*

Relationship:*

Phone Number:*

Shirt Size:*

Each session will last 6 weeks and will be held on Wednesday evenings. Please select the session that works best for you and your child below.

May 14-June 18September 10-October 15

What is the participant's health diagnosis?*

Does the participant have an IEP or 504 Plan?*

YesNo

Is the participant taking any medication?*

YesNo

If yes, please specify:

Is the participant have any allergies?*

YesNo

If yes, please specify:

Will your rider potentially need bathroom assistance?

yesno

We want to pair your child with the right buddy and some volunteers may not be able to commit to every meeting for the entire Riding Warriors session. Does your warrior have a difficult time with change and bonding with new faces?

yesno

Please list any special accommodations the participant may need to ensure the best outcome in our Riding Warriors program:*

What types of behaviors are shown by the participant when they are nervous or scared? What calms the participant?*

Does the participant use adaptive devices like a cane, wheelchair, braces, walker, or crutches? If yes, please explain:

Has the participant ever ridden a horse or been involved in therapeutic riding?*

What are your riders special interests (e.g., toys, hobbies, artists)?*

Please upload a headshot of your rider below. This is solely for session purposes, helping us match names with faces as we get to know your rider.*

Media Release Form

I consent to and authorize the use and reproduction by Sams Ranch of any and all audio and visual materials taken of me and my child or the participant for whom I am the legal guardian. I understand that any artwork produced of me and my child or the participant for whom I am the legal guardian may be used for promotional material, educational purposes, exhibitions, or any use that may benefit the Riding Warriors program.

Do you consent?*

YesNo

Signature of Parent or Guardian*

I, the undersigned, understand that participation in the Riding Warriors Equine Therapeutic Riding Program involves certain risks and that the program, its staff, and volunteers will not be held responsible for any accidents or injuries that may occur. I give my consent for the participant named above to engage in equine therapy sessions at Sams Ranch and agree to follow all program rules and instructions.

Emergency Medical Treatment Release Form

In the event of an emergency and medical aid treatment is required, I, the parent/legal guardian, permit Riding Warriors at Sams Ranch to secure and retain medical treatment and transportation if needed, along with releasing the participant's medical record upon request to the authorized individual or agency involved in the medical emergency. The authorization includes allowing x-rays, surgery, hospitalization, medication, and any treatment procedure deemed "life-saving" by a physician. This provision will only be invoked if contact with the participant's parent/legal guardian has been unsuccessful.

Name of Physician

Preferred Medical Facility

Policy #

Health Insurance Provider

Print name of Participant*

Date*

Date

Signature of Participant (if able)*

Signature of Parent or Guardian*

Rider Application

Session Information:

Important Information: Health & Academic

Consent Section

Liability Release