Cloverleaf Equine Center Client Paperwork

Please describe any abilities/difficulties in the following areas (include assistance required or equipment needed):

This information is filled out to best of my knowledge and I feel there is no reason why this person cannot participate in supervised equine assisted activities. However, I understand that the PATH Intl. center will weigh the medical information above against the existing precautions and contraindications. I will alert the Cloverleaf Equine Center staff to all changes, new progress, or issues that arises with your participant’s health.

Cloverleaf Equine Center Seizure Policy 
 
Purpose 
Cloverleaf Equine Center is committed to providing a safe and supportive environment for all clients. This policy outlines requirements and procedures for clients with a history of seizures to ensure safety for the client, staff, volunteers, and horses. 
 
Seizure Disclosure Form 
All clients with any history of seizures must submit a Seizure Disclosure Form prior to participating in any Cloverleaf programming. 
 
The Seizure Disclosure Form must be updated annually or whenever there is a change in seizure type, frequency, or management. 
 
1. Disclosure Requirement 
Clients with any history of seizures must complete and submit a Seizure Disclosure Form prior to participation in any Cloverleaf programs. 
 
Clients with active or uncontrolled seizures may be required to submit written clearance from their treating physician prior to participating in mounted or unmounted activities. 
 
2. Supervision Requirement 
If a client has a history of seizures, an adult responsible for that client may be asked to remain in sight of the client at all times while they are participating in Cloverleaf programming. 
 
3. Ongoing Communication 
Cloverleaf must be notified immediately of any new seizure activity, changes in seizure frequency, type, or medication. Failure to notify Cloverleaf staff of such changes may result in temporary suspension or dismissal from the program until updated medical information is received. 
 
4. Medication and Medical Devices 
Any medications or medical devices (including magnets for VNS) that must be administered to prevent or control seizures must be administered only by an adult responsible for the client. Cloverleaf staff will not administer medications or procedures for seizure management. 
 
If emergency medications (such as nasal sprays or rectal diazepam) must be available on-site, they must: 
     --Be provided by the client’s guardian or caregiver, 
     --Remain in the custody of the responsible adult, and 
     --Be accompanied by a Seizure Action Plan describing when and how the medication should be used. 
 
5. PATH Intl. Riding Contraindications 
The Professional Association for Therapeutic Horsemanship sets forth precautions and contraindications for therapeutic riding. According to PATH Intl. Standards, the following conditions are contraindications to riding for clients with seizures. 

If any of these conditions are present or occur, the client will be prohibited from riding until the condition is no longer present (or has not occurred for at least three months, as documented by the treating physician): 

     --Recent seizure activity accompanied by strong uncontrollable motor activity, or atonic/drop attack seizures due to sudden and complete loss of postural muscle tone 
     --A change in frequency or type of seizure until the condition is medically evaluated 
     --The client’s weight and physical support needs exceed what can be safely managed during an emergency dismount in the event of a seizure. 

Possible exceptions to the three-month policy may include, but are not limited to: 
     --Very small clients (under 40 lbs.) allowing for an easily managed emergency dismount 
     --Seizures with no motor involvement, such as a brief loss of awareness without significant post-seizure mental or physical effects 
 
Note: Clients restricted from riding may be able to continue to participate in unmounted or ground-based programming when appropriate and safe. 
 
6. Seizure Response Procedure 
If a seizure occurs during a Cloverleaf program, staff will: 
Stay calm and ensure the client’s safety by stopping all activity and clearing the area around the client. 
Work to protect the client’s head from injury but not restrain the client. Time the seizure from onset to end. 
If the seizure lasts longer than five minutes, or if a second seizure follows without recovery, call 911. 
Once the seizure ends, monitor the client’s breathing and responsiveness. 
Notify the guardian or emergency contact as soon as possible. 
Complete a Cloverleaf Incident Report and file it with the Program Director. 
 
7. Staff Training 
All instructors, therapists, and designated staff will receive biannual training in seizure recognition, response procedures, and documentation requirements from the Epilepsy Foundation. Volunteers will be oriented to basic safety procedures related to working with clients who have a seizure history. 
 
8. Alternative Programming 
If a seizure occurs that temporarily restricts a client from mounted activities, Cloverleaf will work with the client and their family to determine if alternative programming can be safely provided until the client is cleared to return to mounted activities. 
 
9. Information Access and Confidentiality 
Cloverleaf instructors and therapists working directly with a client who has a known history of seizures will have access to the client’s Seizure Disclosure Statement and Seizure Action Plan. Volunteers working with such clients will be made aware of pertinent safety information by the instructor or therapist, while maintaining confidentiality.  
 
10. Failure to Disclose 
Clients engaged in Cloverleaf programming who experience a seizure or change in seizure frequency and fail to disclose recent seizure activity may be dismissed from the program at Cloverleaf’s discretion. The decision to restrict or dismiss a client due to seizure activity will be made by the Program Director in consultation with the instructor, therapist, and family, and when appropriate, the client’s treating physician. 

I certify that the above information is complete and accurate to the best of my knowledge.  I understand that Cloverleaf staff will not administer seizure medications and that it is my responsibility to notify Cloverleaf of any changes in seizure type, frequency, or management.

Please read and check each of our policies to indicate that you have read and accepted each policy.

I have read and understand the basic rules and policies under which Cloverleaf Equine Center operates, and by my signature indicate my willingness to abide by these rules:

In consideration of receiving permission from the Cloverleaf Equine Center to participate in or observe equine-assisted services in further consideration of receiving permission to enter upon the Center's property or other premises upon which the Center's activities may be conducted, the undersigned and his/her family, heirs and assigns hereby forever release, acquit, discharge and hold harmless the Center, as well as its officers, directors, staff, agents, instructors, volunteers, contributors and any property or horse owners affiliated with the Center of and from any and all liability, claim, loss, damage, illness, injury, or death that may be sustained by any of the undersigned while in or upon the premises while participating in or observing activities or while traveling to or from the premises.

The undersigned acknowledges that there are certain risks inherent in participation in equine activities including (i) the propensity of an equine to behave in dangerous ways that may result in injury to the participant; (ii) the inability to predict an equine’s reaction to sound, movements, objects, persons, or animals; (iii) the possibility of equipment failure; and (iv) hazards of surface or subsurface conditions. While the Center makes every effort to minimize these risks, the undersigned is duly aware of these risks and hazards inherent upon participation in or observing equine activities and/or upon entering upon the premises and expressly and knowingly assumes these risks. The undersigned shall explain the potential for these hazards and risks to others that may accompany or substitute for him/her at activities sponsored by the Center. These persons also, by their voluntary presence, assume the same risks and agree by their presence to the same release of liability described herein.

The undersigned shall release and hold harmless the Program, its officers, trustees, agents, instructors, volunteers, contributors, and other property or horse owners affiliated with the Program of and from any and all liability, claim, loss, damage, cost, charge, and demand of any kind, including attorney’s fees and any related costs, arising either from the improper or negligent use by the undersigned of any equine, bridle, saddle, grooming tool, and/or other animal or tool or from the willful or negligent acts of the undersigned.

For valuable consideration given and which is hereby acknowledged, the undersigned hereby grants permission to Cloverleaf Equine Center to take or have taken, still and moving photographs and films including television pictures of my daughter/son/ward/self and consents and authorizes Cloverleaf Equine Center, PATH Intl., news media, and any other persons interested in the subject of equine-assisted services and its work, to use and reproduce the photographs, films and pictures and to circulate and publicize the same by all means including and without limiting the generality of the foregoing newspapers, television media, brochures, pamphlets, books, social media including Facebook, instructional material and clinical material.

With respect to the foregoing matters, no inducements or promises have been made to me to secure my signature to this release other than the intention of the Cloverleaf Equine Center to use or cause to be used such photographs, films, or pictures for the primary purpose of promoting and aiding the field of equine-assisted services and its work.

Please review and verify all your information is correct, then Submit.