HTR Mini Camp Application

Camper Information:

Camper Full Name*

First NameLast Name

Camper Birth Date *

Mini Campers must be between 6-14 years old

Is the camper a current HTR rider?*

YESNO

Has the camper attended HTR camp in the past?*

YESNO

If yes, what year(s) did your camper attend?

Camper Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

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.

Emergency Contact's Relationship to Camper*

ParentGuardian

Camper Height *

Camper Weight *

HTR has a weight limit of 180lbs.

Parent/Guardian Information

Parent/Guardian Full Name *

First NameLast Name

Parent/Guardian Address (if different than camper)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Phone (if different than Camper)

Please enter a valid phone number.

Parent/Guardian Email (if different than Camper)

example@example.com

Health and Diagnosis:

Please tell us about the camper's current health, challenges, and needs in the appropriate sections below. Please also make note of any adaptations the camper would require to thrive at camp.

Primary Diagnosis *

Secondary Diagnosis

Cognitive

Physical and Mobility

Communication

Sensory

Emotional/Mental Health

Behavioral

Does the Camper have seizures or have a history of seizures?*

YesNo

Does the Camper use the restroom independently? HTR staff and volunteers may not enter the restroom with campers. If a camper needs help in the bathroom, they must bring a support person with them.*

YesNo, I will supply a support person

Does the Camper need medication administered during camp? HTR staff and volunteers may not administer medication, including emergency/rescue medication to any camper. If a camper needs help with medication, they must bring a support person with them.*

Yes, I will supply a support personNo

Does the Camper Have any Indwelling Devices? Please include type and location. *

Does the Camper have any allergies, sensitivities, or intolerances to food, the environment, medications etc? If so, please list. *

Please tell us about the camper's support needs. For example, what adult/child ratio does the camper need to succeed at school or in the community? Can they succeed in a group setting, or need their own support person? *

Please tell us about the camper's strengths and goals!

Other - Please tell us anything else we need to know about the Camper.

Which camp week and time slot would you prefer?*

Week #1 June 22nd - June 26thWeek #2 July 6th - July 10thEitherBoth

Which time slot would you prefer?*

9:00 - 10:3011:00 - 12:30Either

If a participant is brand new to HTR, they are required to schedule and complete an evaluation ride before camp begins. This evaluation ride helps ensure that the camper can participate safely and will have a positive experience at camp. It also allows our staff to thoughtfully assign an appropriate horse, equipment, and volunteers as needed, so each camper is set up to thrive. The evaluation ride is one time, short, and free of charge.

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*

Date

Type full name of person filling out this form *

Relationship to camper *