Mounted Participant Registration Form

Mounted Participant Registration Renewal

Complete this form ONLY if you are a current participant.
Participant Name (First and Last Name)*
Birthdate*

MonthDayYear
Date
Height*
Weight*
Participant Diagnosis*
Gender Identitiy
Preferred Gender Pronoun
Ethnicity*
How did you hear about us?
Participant's School/Employer
Name of person filling out this form*
Email address of person filling out this form*
example@example.com
County Participant Resides In *
Other County
Is the participant or 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
Service Component if applicable
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 Phone Number*

Area CodePhone 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

Area CodePhone Number
Primary Parent/Guardian Home Number

Area CodePhone Number
Primary Parent/Guardian Work Number

Area CodePhone 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

Area CodePhone Number
Secondary Parent/Guardian Home Number

Area CodePhone Number
Secondary Parent/Guardian Work Number

Area CodePhone 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?
Caregiver Information (if applicable)
Caregiver First Name
Caregiver Last Name
Caregiver Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caregiver Email
example@example.com
Caregiver Phone Number

Area CodePhone Number
What is the best way to get a hold of you?

Emergency Contacts
Emergency Contact #1
Name*

First NameLast Name
Relation*
Phone Number*

Area CodePhone Number
Emergency Contact #2
Name*

First NameLast Name
Relation*
Phone Number*

Area CodePhone Number

Medical Information
Physician's Name*

First NameLast Name
Physician's Phone*

Area CodePhone Number
Preferred Medical Facility*
List any Allergies:*
Current Medications:*
Significant Medical History:*
Signature of Participant or Parent/Guardian*

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Today's 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 photo*
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*

MonthDayYear
Date

Consent To Treat
I First Name Last Name participant or the legal guardian of First Name Last Name (Participant Name) hereby consent to evaluation by an occupational, physical, speech, or mental health therapist prior to or during participation in HETRA programming. If physical therapy, occupational therapy, speech therapy, or mental health therapy as well as substance use therapy is deemed appropriate, I give consent for treatment and/or telehealth services as outlined by the therapist which could consist of individual or group programming. I understand my session may consist of a co-facilitation session (therapist and instructor both involved in session) or co-treatment session (two therapists from different disciplines involved in same session). I understand that volunteers will be part of the session as horse handlers, sidewalkers or assistants.
Signature of Participant or Parent/Guardian*

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Today's Date Consent to treat*

MonthDayYear
Date

Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL AND PERSONAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS FORM CAREFULLY

OUR LEGAL DUTY

Heartland Equine Therapeutic Riding Academy is required by law to protect the privacy of your personal and health information, provide notice about our information management practices, and follow the information protocols described below.

USAGES AND DISCLOSURES OF HEALTH INFORMATION

Heartland Equine Therapeutic Riding Academy uses your personal and health information primarily for treatment, obtaining payment for treatment, conducting internal administrative activities, and assessing the quality of care we provide. We use your personal information to contact you for scheduling, billing and providing organizational information.

Heartland Equine Therapeutic Riding Academy will obtain your written permission and authorization before disclosing your personal health information. If you provide us with written authorization to release your information for any reason, you may later revoke that authorization to stop disclosures at any time. If and when any changes are made in our privacy and confidentiality policies, a new Notice of Information Practices will be posted in the same area for public view. You may request a copy of our Notice of Information Practices at any time. Our HIPAA Compliance Officer is Edye Godden and can be reached by calling the office at (402) 359-8830.

PATIENTS INDIVIDUAL RIGHTS

You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct inaccurate or incomplete information in your records. You also have a right to request a list of instances where we disclosed your personal health information for any reasons other than for treatment, payment, or other related administrative purposes. You may request in writing that we not use or disclose your personal health information for treatment, payment or administrative purposes except when specifically authorized by you, when required by law, or in an emergency. Heartland Equine Therapeutic Riding Academy will consider all such requests on a case-by-case basis. The company is not legally required to accept the requests.

CONCERNS AND COMPLAINTS

If you are concerned that Heartland Equine Therapeutic Riding Academy may have violated your privacy right or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our HIPAA Compliance Officer, Edye Godden, at the office address listed below. You may also send a written complaint to the U.S Department of Health and Human Services.

Heartland Equine Therapeutic Riding Academy
HIPAA Compliance Officer
Edye Godden

10130 S. 222 nd Street, Gretna, NE 68028
Phone: (402) 359-8830

Every patient must receive a copy of this form.
Patient Name*

First NameLast Name
Signature of Participant or Parent/Guardian*

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Today's Date hipaa *

MonthDayYear
Date

Safety Rules For All HETRA Staff, Volunteers, 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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Today's Date barn rules*

MonthDayYear
Date

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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Today's Date social media*

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Date
Should be Empty:

Mounted Participant Registration Renewal

Military Information

First Responder Information

Adult Participant Information

Primary Parent/Guardian Information

Secondary Parent/Guardian Information

Caregiver Information (if applicable)

Emergency Contacts

Medical Information

HETRA Billing Policies

Individual Responsible For Payment

Liability Release

Photo Release

Emergency Medical Treatment Consent

Consent To Treat

Notice of Privacy Practices

Safety Rules For All HETRA Staff, Volunteers, Families, and Participants

HETRA Photography and Social Media Policy