Public Riding Registration Form

Public Riding Registration Form
Welcome!
Dear Parents, Guardians, Caregivers, or Participants,

Thank you for choosing HETRA. We look forward to working with you! Please read through all the provided information thoroughly. It contains very important information regarding registration of your Participant and participation in the HETRA program.

We are very excited about everything we have accomplished over the past few years! In order to keep the program affordable to all of the participants, HETRA continually hosts fundraising events and activities and looks for grants and foundations to help support our program. HETRA continues to be committed to providing services to our Participants regardless of their financial situation or ability to pay. With this commitment though, we need help from all of our HETRA families to assist with our fundraising efforts throughout the year.

We are very proud of our dedicated and motivated parents, guardians, and Participants and all that you do for the HETRA organization. You are a very important part of our Team!!!! We are looking forward to embarking on another adventure with you.

Thank You!

Edye Godden, OTR/L

Chief Executive Officer
www.HETRA.org
Edye@HETRA.org
402-359-8830

1. Getting Started
  
  First please complete all paperwork included in this package.Once your paperwork has been received and processed new Participants will be contacted to discuss possible ssession riding times.
  
  There will be a $35.00 annual registration fee for all Participants.
2. Programs
  
  HETRA has opened up our center to individuals in the public that would like to come take riding lessons. The participant must be at least 5 years old.
  
  Sessions with 1-2 riders in the class will be 30 minutes lessons, if there are 3 participants the session will be 45 minutes long. All sessions will be taught by one PATH, Intl. certified instructor. Goals for this program focus on horsemanship skills and leisure activities.
3. Participant Dismissal & Discharge Policy
  
  It is at the discretion of HETRA’s Staff to accept or remove a Participant from the program. The results of a risk/benefit analysis will also be considered. Participants who do not adhere to the rules and procedures or meet the guidelines for eligibility are subject to dismissal or discharge.
  
  Possible grounds for dismissal may include but are not limited to: conduct endangering another Participant or staff or the horse, conduct endangering themselves, consistent failure to follow safety procedures with respect to the horses & facility, a gain in weight above the HETRA maximum levels, frequent cancellations or no shows. The development of a contraindicated condition or the deterioration of a condition to the point horseback riding is no longer beneficial or could be harmful to the participant or where safety for the Participant or others has become a concern.
  
  Participants at HETRA shall have no history of inappropriate behavior with fire or any tendencies or history of abuse or violence directed toward other people or animals. HETRA reserves the right to deny services to any individual based upon concerns for the applicant’s safety and/or the safety of the horses, volunteers, staff, facility, or for other reasons in accordance with PATH, Intl. operating center guidelines.
  
  No Participant will be dismissed without an opportunity to discuss the reasons with supervisory staff. The Participant may at any time, for whatever reason, decide to sever the Participant's relationship with HETRA. Notice of such a decision should be communicated as soon as possible.
4. Weight Limitations for All Participants
  
  Maximum weights are listed below, but decisions regarding participation will be based on the availability of a suitable horse related to the height, weight, cognition, and balance of the participant. The maximum weight for participants cannot exceed 220 pounds. Each horse has individual weight limitations based on the horse’s weight, age, and physical condition. Not all horses can manage the maximum weights listed below. The weight limit may be lowered as determined by available equines and the ability of staff and volunteers to safely support the participant at the time services are requested. HETRA staff will evaluate the participant’s weight and physical abilities to determine if riding is a safe and appropriate activity based on available equine, staff, and volunteers. Weights are checked once every 12 weeks using the HETRA scales with participants wearing the appropriate riding gear.
  
  220 lbs. for a well-balanced centered Participant not requiring sidewalkers.
  180 lbs. for an unbalanced Participant needing sidewalker assistance.
5. Scheduling of a weekly riding time for new Participants
  
  The HETRA staff will place participants in a class based on their riding skills and the current open time slots that work for your schedule. If an opening does not currently exist, then we will put your participant on a waiting list and you will be notified as soon as an opening becomes available. Riding sessions are typically offered late afternoon to evening on weekdays and mid-day on the weekends, available riding times will be discussed at your evaluation.
6. Attire
  
  No open-toe shoes, sandals or clog-type shoes. No slick (jogging type) pants. It is preferred that the Participant wear pants instead of shorts as the saddle can get very uncomfortable with direct skin contact. In the winter, please dress in layers.
7. Children
  
  All children under the age of 12 must be monitored and in the direct vision of the adult at all times while at the facility. Please review the barn rules with your children prior to arriving at the barn.
8. Dogs and Other Animals
  
  Dogs and other animals are not permitted at the barn. The exception to this rule is service animals. Please let your instructor know if you will be bringing a service animal to the session with you.
  
  Thank you so much for your interest in our programs. We look forward to working with you. If you have any questions or concerns, please contact the HETRA office at 402-359-8830.

Participant Registration Form
Participant Name*
Birthdate*

MonthDayYear
Date
Participant's Weight*
Ethnicity*
Gender Identitiy*
Preferred Gender Pronoun
County Participant Resides In *
How did you hear about us?
Participant's School/Employer
Program Interest*
Name of person filling out this form*
Email address of person filling out this form*
example@example.com
Will this be the first time the participant has ridden?*

YesNo
In order to help us place you in a class with other participants working on similar skills, please tell us about their riding experience and interests:*
Has the participant ever taken riding lessons? If so, please tell us what type of lessons, when and where you took lessons.*
Which riding discipline does the participant prefer?*

EnglishWesternBothNot sure
Does the participant own or have access to a horse?*

YesNo
What does the participant/parents hope to learn in their lessons?*

Is the participant's parent/guardian an active or retired military veteran or first responder? *
Military Information
What is your Military Status?
What branch of the Military?
Military Rank
Dates of Military Service
Are you a Wounded Warrior?*
Are you a Wounded Warrior Project alumni?*
First Responder Information
What is your job title as a First Responder?
Which of the following describes the Participant? *
Adult Participant Information
Participant First Name*
Participant Last Name*
Participant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Mobile Phone*
Please enter a valid phone number.
Participant Email*
example@example.com
Primary Parent/Guardian Information
Primary Parent First Name*
Primary Parent Last Name*
Primary Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Parent/Guardian Email
example@example.com
Primary Parent/Guardian Mobile Number
Please enter a valid phone number.
Primary Parent/Guardian Home Number
Please enter a valid phone number.
Primary Parent/Guardian Work Number
Please enter a valid phone number.
Primary Parent/Guardian Place of Employment
Primary Parent/Guardian Title/Occupation
What is the best way to get a hold of you?
I am the legal guardian of this participant and can provide documentation upon request:
Secondary Parent/Guardian Information
Secondary Parent First Name
Secondary Parent Last Name
Secondary Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Parent/Guardian Email
example@example.com
Secondary Parent/Guardian Mobile Number
Please enter a valid phone number.
Secondary Parent/Guardian Home Number
Please enter a valid phone number.
Secondary Parent/Guardian Work Number
Please enter a valid phone number.
Secondary Parent Place of Employment
Secondary Parent Title/Occupation
I am the legal guardian of this participant and can provide documentation upon request.
What is the best way to get a hold of you?

Medical Information and Insurance
Physician's Name*

First NameLast Name
Physician's Phone*
Please enter a valid phone number.
Preferred Medical Facility*
Emergency Contact #1
Name*

First NameLast Name
Relation*
Phone Number*
Please enter a valid phone number.
Emergency Contact #2
Name*

First NameLast Name
Relation*
Phone Number*
Please enter a valid phone number.
This participant does NOT have a physical, developmental, or mental health diagnosis and is NOT currently receiving treatment for physical, developmental, or mental health symptoms.
Signature of Participant or Parent/Guardian*

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Today's Date*

HETRA Billing Policies
If you have any questions about HETRA’s fees or billing procedures please contact Erin Bevington at (402) 359-8830, ext 105 or Erin@HETRA.org

To help HETRA save on postage, all invoices are sent via email.
If would prefer to receive your billing via regular mail, please let us know.

Fee Structure

HETRA does not bill health insurance or Medicaid

Public Riding Program: Fee is $45 per ride/drive and will be billed in 12-week courses ($540). prior to the beginning of the course.

Registration Fees: All new Participants will be billed an $50.00 registration fee, which helps HETRA cover insurance and other office fees. Going forward there will be an annual $40 registration fee at the beginning of each year.

Any Participant with an outstanding balance from the previous course will not be allowed to participate until the balance on the account has been paid, payment arrangements have been made or the scholarship application completed. All Participant fees that are past due by 30+ days or are not paid according to the previous payment arrangements, will be assessed a minimum of $20.00 charge per month.

Cancellations

You will be notified by phone, email and/or text message for weather cancellations.

If HETRA cancels a session (due to weather or staff illness, etc.): The fees for each HETRA cancellation will be credited toward the next 12-week course invoice.

If a participant cancels a session: This session will not be available for a refund.

Participant tardiness: Any time a Participant is late, their session time will be decreased accordingly in order for the schedule to remain intact. If a Participant is 15 or more minutes late for a session they will NOT be allowed to ride for that session.

Dropping out of a Course: If your Participant drops out of a 12-week course without finishing all 12 weeks there will be a $50 fee assessed unless it was medically necessary.
As we grow and expand our services, we frequently are asked by funders the income ranges of the participants we serve. This information will only be used for fundraising purposes and will not in any way influence your registration or participation at HETRA. Your voluntary response is greatly appreciated and will help HETRA continue to receive funding from our community.
Number of Members in Household*
What is your total household income:*

Less than $25,000$25,001 to $45,000$45,001 to $60,000$60,001 to $75,000$75,001 to $100,000over $100,00Prefer not to answer
Individual Responsible For Payment
Who is responsible for payment? *
First & Last Name of who is responsible for payment
Relationship to Participant
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By signing below, I agree that I have read and understand HETRA's billing policies and agree to pay all applicable fees.
Signature of Participant or Parent/Guardian

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Today's Date Billing*

MonthDayYear
Date

Liability Release
First Name* Last Name* would like to participate in the Heartland Equine Therapeutic Riding Academy program. I acknowledge the risks and potential for risks of equine-assisted activities. However, I feel that 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 against Heartland Equine Therapeutic Riding Academy, its Board of Directors, Instructors, Therapists, Aides, Volunteers, and Employees for any or all injuries and/or losses I/my son/my daughter/my ward may sustain while participating in Heartland Equine Therapeutic Riding Academy Programs.
Warning - Under Nebraska Law, an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities pursuant to sections 25-21,249 to 25-21,253
Signature of Participant or Parent/Guardian*

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Participant, Parent, Guardian
Today's Date Liability

MonthDayYear
Date

Photo Release
Please select one*
the use and reproduction by Heartland Equine Therapeutic Riding Academy of any or all photographs and any other audiovisual materials taken of me/my son/my daughter/my ward for promotional printed material, educational activities or any other use for the benefit of the program.
Signature of Participant or Parent/Guardian*

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Participant, Parent, Guardian
Today's Date photo*

MonthDayYear
Date

Emergency Medical Treatment Consent
This release provides authorization for emergency medical treatment including but not limited to x-ray, surgery, hospitalization, medication, and any treatment procedure deemed “life saving” by a physician or emergency medical personnel in the case of emergency. This provision will only be invoked if the parent/guardian or emergency contact is unable to be reached.
Please select one med*
Signature of Participant or Parent/Guardian*

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Today's Date Med Consent*

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Date

Safety Rules For All Families, and Participants
These guidelines have been developed for your safety. Failure to follow these rules can result in dismissal from this facility.
1. Please DO NOT pet the horses in any outside pens or indoor stalls. Some horses on the property are privately owned and are not part of the HETRA herd.
2. Please do not arrive at the barn before you are scheduled. There must be a HETRA Instructor, Staff Member, or Barn Leader on site when volunteers, students or guests arrive. For insurance purposes there cannot be visitors at the HETRA facility when there is not a staff member on site.
3. ONLY the Barn Leader or approved Horse Leader will be allowed to get horses from outside pens.
4. No untrained individual should enter a pen or stall with a loose horse in it.
5. You should not be in any outside pen UNLESS you have been asked by an Instructor or Barn Leader to complete a specific task in this area. Once this has been completed please return to the proper volunteer areas.
6. NEVER sit, kneel or lay on the ground near a horse.
7. All phones must be turned to silent or vibrate when in the arena. NEVER answer your phone while working in the arena.
8. Please only use HETRA tack and equipment and always return it to its appropriate place.
9. Always clean up after yourself and any horse you are working with (sweep up any hair, manure, and throw away any trash).
10. All riders during a HETRA riding session are required to wear approved safety helmets (this includes Instructors).
11. Please do not feed any horses treats. Treating horses tends to promote biting. Also some of the horses are on special diets and
  treats can be detrimental to their health. Please do not allow the horses to lick your hands this encourages biting.
12. Please DO NOT pet the horses on their heads or faces. This is a personal space for them and can make them crabby.
13. When approaching a horse, always consider the horse’s limited field of vision. Horses cannot see directly behind or in front of them without moving their head. Always approach a horse at the shoulder, speak to them as you approach, and then extend your hand and pat them on the neck or shoulder. When moving around a horse, placing a hand on their hip as you move around them allows them to know where you are.
14. Avoid sudden movements when around the horse. This includes removing coats, raising arms suddenly, running, jumping climbing, etc. Horses can spook easily, please keep this in mind at all times when around horses.
15. Please DO NOT reach into or pet a horse through the bars. If they can put their heads out, it is ok to pet them. Please respect that they may need down time and do not want to be petted.
16. Only HETRA Instructors are allowed to put on or remove the bridles on the HETRA horses.
17. Please do not bring dogs or any other animals to the barn. (If you have a service animal please notify HETRA Staff).
18. The cats are cute and fun to play with, but they can bite and scratch. Playing with the cats is done at your own risk. Please monitor any children during their interaction with the cats.
19. All children under the age of 12 must be DIRECTLY monitored by an adult at all times while on the property. Child must be in direct line of sight and adult must not be participating in any other activities such as volunteering or riding.
20. DO NOT enter any other buildings on the property unless directed by a HETRA Instructor or Staff Member.
21. If you are not directly involved with a session please keep all activities and conversations to the designated waiting areas. It is important to keep noise and conversation to a minimum when lessons are being conducted as it can be very distracting for the participants and horses.
22. The HETRA Instructors are ultimately responsible for all aspects of the session from the time the first horse is taken out until the last one is put away. Please listen and follow all directions given by the session Instructors. Please be aware of all situations around you and report any unsafe situation to the session Instructor or Barn Leader immediately.
23. HETRA strictly prohibits anyone, including individuals with permits, to carry concealed handguns, from possessing and/or carrying a concealed handgun while on HETRA's property. NO EXCEPTIONS will be made to this Policy. Any violation may result in the dismissal of Volunteer or Guest.
24. HETRA is a Tobacco Free Facility. Smoking or the use of any tobacco products is strictly prohibited on the HETRA property. This includes the arena/barn area as well as the parking lot and adjacent buildings on the property.
HETRA does not discriminate on the basis of race, color, religion, national origin, gender, age, or disability in admission to its programs, services, or activities, or any other aspect of their operations.

HETRA Volunteer and Guest Dismissal Policy: HETRA reserves the right to dismiss a guest or volunteer from the facility and the program if their behavior is putting themselves, a participant, staff, other volunteers or the horse’s mental or physical health in jeopardy. The HETRA instructor in charge at the time of the incident will review the behavior with the volunteer/guest and determine the level of intervention necessary. The level of intervention could include a verbal or written warning or immediate dismissal from the HETRA facility and program. Physical, emotional, mental or sexual abuse by a person at the HETRA facility will not be tolerated and will result in immediate dismissal from the HETRA facility. Alcohol consumption by a volunteer prior to a session is not allowed. A volunteer/guest smelling of alcohol will not be allowed to assist with that night’s session.

Please follow these rules at all times while at the facility. Anyone not following these rules will be asked to leave the facility.
I am signing these rules as the Parent or Guardian for the family of Participant's Name
Signature of Participant or Parent/Guardian*

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HETRA Photography and Social Media Policy
Videos and Photography taken at the HETRA Facility Policy:

Due to the sensitive and personal nature of our participants and the services we offer, we must exercise every precaution to protect our privacy and confidentiality policies. For that reason, ONLY HETRA STAFF MEMBERS ARE AUTHORIZED TO TAKE PHOTOS/VIDEOS OF ANY HETRA PARTICIPANT, VOLUNTEER, HETRA FACILITY, HORSE, OR EMPLOYEE. If you would like a phot/video taken, please as one of our staff members. Photos/videos may only be taken on the staff member's phone or other authorized HETRA authorized equipment. All photos/videos will be submitted to our photo/video committee for approval. Once approved, the photo/video will be provided to the requester, along with permission to post/use it.

Procedure for pictures or videos of their participants while at HETRA.
1. Please notify your instructor or therapist that you would like a particular picture or video taken of your participant.
2. HETRA instructor or therapist will supervise taking of the picture on a HETRA approved devise.
3. Once the picture/video has been taken it will be sent to the designated staff for approval (this allows the staff to check photo releases on everyone and make sure other participants/volunteers are not in the photo and there is no confidnetiality issues realted to the photo). Designated staff includes - CEO, COO, Eqine Operations Mnager and Program Manager.
4. Once approved the photo will be sent to the requesting party. We will do our best to make this a very timely process.
Social Media:
Heartland Equine Therapeutic Riding Academy (HETRA) embraces social media and relies on our participants, staff, and volunteers to increase our online presence and build our brand. It is one of the most powerful platforms we have to share our mission, create positive awareness for our organization, and engage with our community on a daily basis. We highly encourage participants to engage with HETRA’s social platforms by liking, commenting, and sharing our posts.

Where to find HETRA:
Facebook Heartland Equine Therapeutic Riding Academy (HETRA) Twitter @HETRA
Snapchat Team HETRA
Instagram team_HETRA
You Tube HETRANebraska
Linked In Heartland Equine Therapeutic Riding Academy (HETRA)

ALWAYS:
- Help HETRA spread the good word - share, retweet, and regram HETRA posts on your own social platforms.
- Refer to HETRA horses in a positive manner and forward inquiries about HETRA horses to a staff member.
- Think twice before posting. If you have any doubt, please do not post.
NEVER:
- Claim to be an official representative of HETRA.
- Share confidential information about a participant, volunteer, employee or the organization.
- Take photographs or video of a HETRA participant, volunteer, HETRA facility, horse or employee unless specifically approved to do so by a designated staff member.
- Use language that is profane, harassing, racial, political, religious, or that is considered biased or slurred when posting about HETRA.
- Refer to a HETRA horse or the HETRA barn environment negatively.
Violation of Social Media Policy
If a social media post is discovered that is in violation of this policy, you will be asked by a staff member to remove the post. Failure to remove a post could result in verbal or written warning or immediate dismissal from the HETRA facility and program.
Signature of Participant or Parent/Guardian*

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Public Riding Registration Form

Welcome!Dear Parents, Guardians, Caregivers, or Participants,

Participant Registration Form

Military Information

First Responder Information

Adult Participant Information

Primary Parent/Guardian Information

Secondary Parent/Guardian Information

Medical Information and Insurance

HETRA Billing Policies

Individual Responsible For Payment

Liability Release

Photo Release

Emergency Medical Treatment Consent

Safety Rules For All Families, and Participants

HETRA Photography and Social Media Policy

Welcome!
Dear Parents, Guardians, Caregivers, or Participants,