2025 Participant Application

Participant Name (first & last)*

DOB*

Age*

Gender*

MaleFemale

Ethnicity

This info used for many Grant applications, Thank you.

Height*

Weight-(180 # weight limit for safety of horse and volunteer purposes, ground lessons are available for participants weighing more than limit)*

Participant Address*

Participant Address

Street Address Line 2

CityZip

Home Phone

Mother's Name*

Participant Cell Phone, if applicable

Email*

example@example.com

Mother is Primary Contact*

YesNo

Mother's Address- if same as participant enter "same"

Address

Street Address Line 2

City

Zip

Mother's Cell Phone*

Father's Name*

Father's Address- if same as participant enter "same"*

Address

Street Address Line 2

City

Zip

Father is Primary Contact*

YesNo

Father's Cell Phone*

Guardian's Name,

Guardian is Primary Contact

YesNo

Guardian's Address

Address

Street Address Line 2

City

Zip

Guardian's Cell Phone

Who does Participant live with? *

If participant lives in group home, please provide a contact name & number for last minute cancellation.

Group Home is Primary Contact

YesNo

Participant attends which school? enter "none" if not in school.

What city is school located in?

How did you hear about the program?

Referral source?

Referral Phone

Primary Diagnosis - *

Date of Onset*

Date

Secondary Diagnosis

Date of Onset

Date

Medications include prescription, over the counter, name, dose, and frequency*

Please answer the following questions describing abilities/difficulties in the following areas (include assistance required or equipment needed):

Vision*

YesNo

Hearing*

YesNo

Sensations- Sensory*

YesNo

Communications*

YesNo

Heart*

YesNo

Breathing*

YesNo

Digestion*

YesNo

Elimination*

YesNo

Circulation*

YesNo

Emotional/Mental Health*

YesNO

Behavioral*

YesNo

Pain*

YesNo

Bone or Joint*

YesNo

Muscular*

YesNo

Thinking or Cognition*

YesNo

Alergies*

YesNo

Allergies to medications*

If you answered Yes to any of the above questions, please give us as much detail as possible.

Comments to health questions

Physicians Name

Preferred Medical Facility*

Health Insurance Company*

Policy*

Current medications*

In the event of an emergency, contact: Please give us two contacts

Name- 1st contact*

Relation*

Phone*

Name- 2nd contact*

Relation*

Phone*

PHYSICAL FUNCTION- Mobility skills such as transfers, walking, wheelchair use, driving, bus riding, etc*

PHSYCO/SOCIAL FUNCTION- Work/school including grade completed, leisure interests, relationships,family structure, support systems, companion animals, fears, concerns, etc.*

GOALS- What do you want to accomplish by participating? Why are you applying for participation?*

Photo Release

Photos may be taken during lessons. Please tell us if you consent to those photos of your child being used in our marketing, promotional material, educational activities, exhibitions, or for any other use for the benefit of the program. We will not use photos if you do not consent.

Photo Consent - select one*

I doI do not

I fully understand that the activity of horseback riding, or even being near a horse, involves numerous dangers and risks of injury to me or my child.

I acknowledge the assumption of all the risks involved in my responsibility, and I completely release Loving Thunder Therapeutic Riding Inc. and its agents from all liability for any and all injuries caused by my participation in the general activity of horseback riding.

I fully understand that an animal (horse)irrespective of its training and usual past behavior and characteristics, may act or react unpredictably based on instinct or fright, and that even the gentlest horse, when provoked or frightened, may rear buck, run away or otherwise act in an unpredictable and dangerous manner.

In addition, weather such as wind, thunder, hail, lightning, or snow sliding off of the roof, may cause a horse to rear, buck, run away or otherwise act in an unpredictable and dangerous manner.

Having understood these dangers, I fully assume all of the risks involved and completely release Loving Thunder Therapeutic Riding, Inc and its agents from liability for any and all injuries to me from the general activity of horseback riding.
I fully understand that riding on any type of terrain can be dangerous to my horse and me, and that this danger increases when riding a horse fast, such as a canter (LOPE) OR AT A GALLOP. Under these conditions, or even while riding at a slower pace, my horse may stumble, be thrown off balance, get caught in a hole or rut, fall, or otherwise be dangerous to me.

I also fully understand that I or my child may, at any time, lose control of and/or fall off my horse, or have a collision. I fully assume responsibility for all these dangers and risks, and completely release Loving Thunder Therapeutic Riding, Inc and its agents from all liability for all injuries to me from the dangers and risks as stated above.

I fully understand that animals (horses) and conditions are unpredictable and that the risk of injury or death is inherent to the activity of horseback riding and/or being around horses.

I fully assume the responsibility for the risk of injury or death caused by my contact with horse and horseback riding. I completely release Loving Thunder Therapeutic Riding, Inc. and its agents from all liability for all injuries or death to me caused by my contact with horses and/or horseback riding.

I agree not to sue, claim against, attach the property of or prosecute Loving Thunder Therapeutic Riding, Inc, its officers, board members, affiliated organizations, agents and/or its employees for horseback riding and its related activities, whether such injury or death was caused by their negligence or from any other cause.

I agree to release the State of New Mexico and all its agencies, agents, contractors, servants and employees from liability for any acts of Loving Thunder Therapeutic Riding, Inc causing injuries arising out of premises operation, acts of independent contractors, products completion, or personal injuries sustained due to Loving Thunder Therapeutic Riding, Inc's negligence in connection with providing services under this contract.

I agree to defend, indemnify and hold harmless Loving Thunder Therapeutic Riding, Inc. and all of its officers, board members, affiliated organizations, agents and employees for any injury or death caused by or resulting from my participation in the activity of horseback riding and its related activities, whether or not such injury or death was caused by their negligence or form any other cause.

This agreement shall be legally binding upon me, my family, my heirs, my estate, assigns, legal guardians, and my personal representative.

I am enrolling my child/myself in Loving Thunder Therapeutic Riding, Inc's programs. I have carefully read this agreement and fully understand its contents. I am aware that I am releasing certain legal rights that I otherwise may have, and I enter into this release of liability and indemnity agreement on behalf of my child or myself of my own free will. I agree with the above-mentioned statements.

THIS IS A RELEASE OF LIABILITY. DO NOT SIGN OR INITIAL THE RELEASE IF YOU DO NOT UNDERSTAND AND/OR AGREE WITH ITS TERMS.

Participants under 18 years of age requires the signature of a parent or legal guardian.

I fully understand that riding on any type of terrain can be dangerous to my horse and me, and that this danger increases when riding a horse fast, such as a canter (LOPE) OR AT A GALLOP. Under these conditions, or even while riding at a slower pace, my horse may stumble, be thrown off balance, get caught in a hole or rut, fall, or otherwise be dangerous to me.