Enrollment Packet

Enrollment Packet

PARTICIPANT’S APPLICATION AND HEALTH HISTORY
General Information
Participant*

First NameLast Name
Parent/ Guardian
Age of the Rider*
Date Of Birth*

MonthDayYear
Date
Height*
Ft and In
Weight*
Lbs
Gender*
Male or Female
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer/School
How did you hear about us?
Referral Source
Name of Organization or Person

Photo Release
Type a question*

I do consent...I do not consent...
... and authorize the use and reproduction by of any and all photographs and any other audio/visual materials taken of me for promotional material educational activities, exhibitions or for any other use for the benefit of the program.
Signature (Parent/Guardian) *

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Date*

MonthDayYear
Date

GOALS OF THE RIDER
Long Term Goals:
Short Term Goals:
Specific activities/ exercises being used to achieve these goals:
Behaviors to be encouraged:
Behaviors to be discouraged:
What is the rider’s major challenge, if any:
Rider’s likes, dislikes, interests, hobbies:
Behavior patterns which may effect our work with this rider:
What is the most effective method used in communicating with this rider:

Authorization for Emergency Medical Treatment Form
Physician’s Name
Preferred Medical Facility
Health Insurance Company
Policy
Allergies to Medications
Current Medications:
In the event of an emergency, contact:*

First & Last NameRelation
In the event of an emergency, contact:

First & Last NameRelation
In the event of an emergency, contact:

First & Last NameRelation
In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency,

I authorize Hopeful Hearts staff or volunteers to:

1. Secure and retain medical treatment and transportation if needed.

2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
Please select one of the following:*

I DO Consent Plan: This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed“lifesaving” by the physician. This provision will only be invoked if the person(s) above is unable to be reached.I do NOT give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. In the event emergency treatment/ aid is required, Iwish the following procedures to take place
Signature

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Date

MonthDayYear
Date

Participant's Consent for Release of Information
I hereby authorize: the staff of Hopeful Hearts Therapeutic Riding to release information from the records of:

First NameLast Name
The information is to be released to:
Center or Therapist's Name
for the purpose of developing an equine activity program for the above named participant. Theinformation to be released is indicated below:

Medical HistoryPhysical Therapy evaluation, assessment and program planOccupational Therapy evaluation, assessment and program planMental Health diagnosis and treatment planIndividual Habilitation Plan C.I.H.PJClassroom Individual Education Plan C.I.E.P.Psychosocial evaluation, assessment and program planCognitive-Behavorial Management PlanOther
If you selected other, please explain:
Signature

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Date

MonthDayYear
Date

TERMS AND CONDITIONS

These policies are established to ensure safe and effective riding lessons.

Lesson Policy Standard:

A lesson is 45-50 minutes in length and is to consist of horse preparation, mounting each client

and tack adjustments, exercises while mounted, cool down time, and dismounting and for some

riders, un tacking, grooming and putting horse back to his pasture. Please note we consider a

lesson starting when the client enters the tack up area through the large entry gate. The instructor

additionally has the responsibility of safety for clients, volunteers, and horses at all times so

therefore, the instructor has the right to deviate from the above lesson outline when safety is a

concern. NO PRIVATE LESSONS are given unless the instructor believes it to be necessary.

Payments:

Therapeutic riding lessons are to be paid at the beginning of each month for the upcoming

month by credit card.

 In case of missed lessons due to illness or vacations with a minimum of 24 hour notice, lessons

will be made up at a schedule agreeable by rider and instructor within the same month.

 It will be the responsibility of the family to contact the Hearts Office at (512) 588-2446 OR the

instructor to schedule make up lessons. If you miss your Lesson with less than 24hours notice a

penalty will be applied. If you need to cancel outside office hours, contact instructor directly via

phone.

Weight limits:

Our weight limit for riding is approximately 180 pounds, depending on the rider's ability to

maintain good balance. No weight limit applies for ground work activities.

Basic Guidelines:

I understand that it is my responsibility prior to entering the arena to inform the instructor of any

new medical or physical problems which may impact my safety or ability to perform correctly

during my scheduled therapeutic riding lesson. I further agree to handle all other questions or

suggestions according to Hearts Therapeutic Riding Program’s policy listed at the end of this

contract.

I understand that lesson times are planned and that I need to be on time. If I am late more than

15 minutes from my scheduled time, my mount will be un-tacked, unless I have made prior

arrangements. I further understand that even if I am late, the time for ending the lesson will

remain as scheduled. I further accept that the instructor is the only person with authority to

cancel any lesson. The only considerations for approved barn cancellation of a lesson are bad

weather conditions (thunderstorms, extreme cold, etc.), a client’s medical absence with a written

doctor’s excuse, or a death in the family. Make-up lessons will only be scheduled for the above

6described lesson cancellations. All management-approved make-up lesson scheduling will be

arranged between the instructor/office and parent/guardian.

I understand that proper attire must be worn for therapeutic riding lessons. Proper attire is pants,

shirt, protective shoes/boots and SEI-ASTM approved riding helmet which fits properly with an

attached harness. A helmet can be provided but it is highly suggested that each rider brings their

own helmet that fits correctly. Ask us where to purchase a helmet and have your helmet fitted.

I further accept that Hearts Therapeutic Riding reserves the right to release a client due to unsafe

situations, physical stress to the client resulting from riding and/or any safety/medical problems

that may arise.

Client’s information files will be held in confidentiality and only shared when necessary to

assure the safety of a client in the treatment or during an official incident review. I am aware of

the inherent risks of being around horses and mounted on horseback and riding. I further

understand that I must be careful while on the property of Hearts Therapeutic Riding particularly

while horses are being handled. Hearts Therapeutic Riding cannot and does not assume any

liability for accidents, injury, or death to person or persons. I further have reviewed and

understand the content of Texas’ Liability Law which is posted at the pasture/arena entrance gate

and in the barn. Likewise, I accept full responsibility for friends and visitors accompanying

myself on Hearts Therapeutic Riding property.

Program Enrollment Policy:

Enrollment in the Hearts Therapeutic Riding Program begins upon program’s receipt of a fully

completed enrollment packet. Make every effort to get the packet turned in prior to a scheduled

lesson but if approved by the instructor, bring the packet to the first lesson. If enrollment packet

is not turned in, a Liability Release form must be signed before riding.

General Conduct Policy for Parents, Clients, and Guests during a Hearts Therapeutic

Riding lesson:

Parent/Client waiting area: Parent/Client waiting area is located on the tack room porch, picnic

tables or in your vehicle. You can watch the lesson at the arena unless it is distracting for the rider.

Arrival to lesson:

If a previous lesson is in progress or dismounting, quietly go to parent/client waiting area.

All clients are to wait at the parent/client waiting area until a volunteer or instructor comes to

escort them. This is for the safety of everyone.

The only people who are to be in the arena/mounting area are the instructor, volunteers and

clients that are getting ready to mount for the current lesson.

If you need to talk to the instructor about medical or physical problems which may have a safety

implication for the current lesson, please do so before the mounting phase of the lesson gets

started.

During the lesson:

To ensure the best possible riding experience, please do not speak with riders during lessons.

While a therapeutic riding lesson is in progress all parents, family members, and guests must stay

in the waiting areas which are the roped off picnic table area, the classroom or their vehicles.

You may only enter the arena if asked by the instructor or volunteer. No loud noises (clapping,

door slamming on cars, loud talking/ laughing, calling to clients, etc.) No umbrellas or flash

7cameras while horses are present. No ball playing, tag games, or fast type movement games

allowed before, during or after lesson schedule times. Please do not bring your dog to the

property.

This policy is for the safety of all. During a scheduled therapeutic riding lesson, our instructor

and volunteers must maintain lesson focus at all times for the safety of our clients.

After therapeutic riding lesson:

After the lesson, the rider will be returned to the parent/guardian.

Confidentiality:

All rider/client information is confidential, and records are kept locked in a file cabinet. Staff and

volunteers are asked to not repeat what is heard in riding lessons and all relationships are to

remain professional.

Question and Suggestion Policy:

If a client or parent/guardian has a question or suggestion pertaining to a client, problem,

complaint, suggestion, etc. please email or call the Executive Director, Lauren Tips at

heartsthr@gmail.com

Equine Waiver & Release Form

Hearts Therapeutic Riding (HTR)

This Waiver and Release from tort and civil liability is made this {date} day

between Equine Activity Participant{participant} and HHTR.

1. Participant understands that there are risks inherent in dealing with horses and ponies (equine activity). For example, Participant understands that some of the inherent risks include:

a. The propensity of an equine to behave in ways that may result in injury, death, or loss to persons on or around the equine;

b. The unpredictability of an equine’s reaction to sounds, sudden movements, unfamiliar objects, persons, or other animals;

c. That there may be hazards, including, but not limited to, surface or subsurface conditions;

d. the possibility of a collision with another equine, another animal, a person, or an object;

e. The potential of an equine activity Participant to act in a negligent manner that may contribute to injury, death, or loss to the person of the Participant or to other persons, including, but not limited to, failing to maintain control over an equine or failing to act within the ability of the Participant;

2. With full understanding of the inherent risks involved in equine activity, some of which have been described in Paragraph 1 above, Participant agrees to wave, release and hold harmless

HHTR from all tort and civil liability arising from or related to participation in equine activity. This agreement to waive, release and hold harmless includes not only HHTR but their employees, volunteers, agents, and independent contractors whether they be trainers, veterinary personnel, farrier’s equine care providers, and maintenance personnel and the like.

3. Participant further understands the examples of the equine activity taking place on or with an equine, including, but not limited to:

a. Riding, jumping, showing, competitions, fairs, trade shows, trail riding, and the like;

b. Teaching, instructing, and evaluation, both the rider and the equine;

c. Routine care and feeding of the equine (Boarding), including veterinary and farrier;

d. Traveling, loading and unloading of equines;

e. Breeding activity, both natural and artificial.

4. This Voluntary Waiver Agreement is made and entered into in the State of Texas and shall be enforced and interpreted under the courts and laws of the State of Texas.

“WARNING”

“Under Texas law (Chapter 87, civil practice and remedies code), 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.

5. Participant agrees that Participant has been given sufficient time to read, understand, and ask questions, if any, concerning the nature and scope of this Voluntary Waiver Agreement.
Should be Empty:

Enrollment Packet

General Information

HEALTH HISTORY

Describe your abilities/difficulties in the following areas (include assistance required or equipment needed)

Photo Release

... and authorize the use and reproduction by of any and all photographs and any other audio/visual materials taken of me for promotional material educational activities, exhibitions or for any other use for the benefit of the program.

GOALS OF THE RIDER

Authorization for Emergency Medical Treatment Form

Participant's Consent for Release of Information