Clone of ANT Volunteer Registration Form

Participant Registration Form
Please contact Lindsey Polson with any questions regarding registration

Email: Lindsey@animalsasnaturaltherapy.org / Office Phone: 360-671-3509
Date of signatures and registration:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Participant

First NameLast Name
Pronouns(optional)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent or Guardian Name (person filling out form)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
School youth is attending:
How did you hear about ANT?

Participant Agreements and Releases
LIABILITY RELEASE: I would like my child/dependent to participate in the Animals as Natural Therapy programs. I acknowledge the risks and potential for risks of horse and farm activities. However, I feel that the possible benefits to my child 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 Animals as Natural Therapy, Inc., its Board of Directors, Instructors, Therapists, Volunteers and/or Employees for any and all injuries and/or losses my child may sustain while participating in Animals as Natural Therapy programming. I understand that these programs may include therapeutic counseling.
Photo/Media Release
I hereby DO/DO NOT consent to and authorize the use and reproduction by Animals as Natural Therapy and their contracted services/funders of any and all photographs and any other audiovisual materials taken of my child for the benefit of the program. Uses may include ANT's public social media accounts, brochures/flyers, marketing & website, grant reporting & stakeholder communications, volunteer training & program documentation.
Signature
I hereby DO/DO NOT consent to and authorize Animals as Natural Therapy staff, volunteers, or other personnel to take photos of my child to be shared with family/guardians and promptly deleted from their personal devices. NOTE: If you have agreed to the media release above, media will be retained in ANT's systems, but not staff personal devices.
Signature
My signature indicates that I acknowledge the exceptions to confidentiality:

Inclement Weather & Emergency Protocol
Animals as Natural Therapy programs operate rain or shine.

If excessive heat or smoke becomes a safety issue for our participants, staff/volunteers, and animals, we may need to cancel a full or half day of camp. ANT follows the United States Equestrian Federation (USEF) regulations for air quality as it relates to outdoor horse/animal activities. These are as follows:

AQI value greater than 150: all outdoor programming will be cancelled.
AQI value between 100-150: programming will continue, with adjustments (minimize physical exertion for humans and animals, no riding).
AQI value below 100: programming will continue as scheduled.

In the case of inclement weather, hazardous air quality conditions, or natural disaster, ANT staff will be in communication and contact you at least 1 hour prior to your scheduled arrival time to cancel.
Natural Disasters/Fire Protocol: In case of natural disaster (fire or earthquake) during program hours, please park along Kline Rd. to allow emergency vehicles the right of way into our single lane driveway and access to our buildings. You will be contacted by ANT staff with details regarding where to meet to pick up your youth.
I have read this policy and understand that I am committed to showing up for program unless ANT has cancelled.

Equine Assisted Learning
EAL is an experiential, skill-building modality that partners people with equines to grow and develop social-emotional skills through relationship with animals, such as: building trust, focus & mindfulness, teamwork, reading body language, setting boundaries, clear communication, self-advocacy, and creative problem-solving.

Participants take part in structured horsemanship activities like leading, grooming, obstacle courses, and more, allowing participants to practice different behaviors and responses with real-time, non-judgmental feedback from their equine partner. In EAL sessions, an instructor and volunteer adult mentor will help participants find a takeaway from their learning that they can apply to other areas of their life.

We may also incorporate small animal activities with rabbits, goats, chickens, dogs, and cats. These sessions help participants build confidence, tools, & strategies needed to make healthy, helpful choices off the farm!
Please note: EAL is not clinical mental health therapy. Sessions are facilitated by PATH Intl. Certified Equine Specialists in Mental Health & Learning and/or Certified Therapeutic Riding Instructors.
I understand that EAL programming at Animals as Natural Therapy is not a clinical mental health therapy. I understand there are no licensed mental health therapists involved in EAL programming.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
For Riding Purposes Only
ANT's programs are relationship and groundwork based. ANT is not a horseback riding lesson program. Instructors may make the decision to facilitate a mounted session in the case that it may benefit the social & emotional goals of the participant or group. Riding is not guaranteed in any program.

Decisions regarding participation in mounted sessions will be based on the availability of a suitable horse related to the height, weight, and balance of the participant. The maximum weight for participants for safe mounted activities at ANT is 220 pounds.

Each horse has individual limitations for riders based upon the horse’s own weight, age and physical condition. Not all horses can manage the maximum weight. The weight limit may be lowered as determined by available equines and the ability of staff and volunteers to safely support the participant at the time services are requested. ANT staff will evaluate the participant’s weight, balance, and physical abilities to determine if riding is a safe and appropriate activity based on available equines, staff and volunteers. All participant information will remain confidential.
Weight (for riding purposes only)
Non-Consent: I understand that if I choose not to disclose my/my child’s weight that I forgo the opportunity to ride if such an opportunity arises.

Authorization for Medical Treatment and Medical Information
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 Name

First NameLast Name
Emergency Contact #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Consent Plan

This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “lifesaving” by the physician.
In the event emergency medical aid/treatment is required due to illness or injury while being on the property of the agency, I authorize Animals as Natural Therapy to secure and retain medical treatment and transportation if needed. This provision will only be invoked if the emergency contact is unable to be reached.
Please make note of any medical information we should be aware of in case of emergency, including allergies and medications. Also include any health reasons to limit participant's activity on the farm.
Year of last tetanus, if known:
Any diet restrictions we should know about:

Financial Agreement & Policies

Please read the following information thoroughly and contact ANT program coordinator with any questions.
ANT’s EAL sessions are $100 per 90-minute group session OR $100 per 60-minute individual session. Group programming total cost at full payment (no scholarship) is $900 per 9-week quarter, with payment in full due by the end of the quarter. A minimum $25 payment is due prior to the beginining of the quarter in order to confirm each participant's registration in our program.

Private EAP sessions (with a therapist present) are $175 per 60 minute session and Private EAL sessions (1:1 with ANT PATH Certified instructor) are $100 per 60-minute session, with payment is due at time of session.

Financial assistance application forms must be submitted at least three weeks before the beginning of the quarter in order to have time to process and approve requests. Proof of income is required. Contact our Program Coordinator with questions or to apply for a scholarship.

Monthly statements will be sent to reflect the total amount due for the quarter. This statement will also show any financial assistance granted. Limited partial scholarships are available based on a sliding fee scale. To apply, please contact our Program Coordinator at lindsey@animalsasnaturaltherapy.org
If you would like to set up recurring payments, please select one of the below options. ANT's Program Coordinator will reach out to discuss the amount, start and end dates for billing.
Other option for recurring payments:
Attendance & Absence Policy
ANT Staff and volunteer mentors commit their time to work with your child to ensure a safe and successful session – we ask that you honor this commitment by making an effort to attend every session.

Please notify us as soon as possible if your child will be absent. Your child is considered “unexcused” if notice is given less than 24 hours prior to their session time. In the case of emergency or sudden illness, please make every reasonable attempt to let us know at least 2 hours prior to your scheduled session time.

An instructor fee will be charged for no-shows, equal to half the normal session fee ($50) for full-pay participant or full agreed-upon session fee for scholarship participants.

Exceptions may be made on an individual basis in the case of emergency or sudden illness.

If a participant misses two (2) sessions without notice within a quarter, future sessions will be cancelled for the quarter and no further financial assistance will be given.
My signature indicates that I have read and agree to ANT's policies regarding billing and attendance in full, and acknowledge that I am responsible for any necessary payment and my child/dependent’s attendance. I understand that the balance for my child/dependent's participation in ANT programming is due at the end of the quarter they are attending.

Participant Registration Form

Please contact Lindsey Polson with any questions regarding registration

Participant Agreements and Releases

Photo/Media Release

Inclement Weather & Emergency Protocol

Equine Assisted Learning

Please note: EAL is not clinical mental health therapy. Sessions are facilitated by PATH Intl. Certified Equine Specialists in Mental Health & Learning and/or Certified Therapeutic Riding Instructors.

For Riding Purposes Only

Authorization for Medical Treatment and Medical Information

Consent Plan

Participant Medical History

Financial Agreement & Policies

Attendance & Absence Policy

Participant Demographics

Thank you for completing ANT Participant Registration! Our Program Coordinator will reach out with additional program details.