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
Date
Name of Participant*

First NameLast Name
Pronouns(optional)
Date of Birth*

MonthDayYear
Date
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
Select to acknowledge the protocol
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.*

YES, I do consent to and authorize media being publicly shared.NO, I do not consent to or authorize media being publicly shared.
Signature*
YES, I do consent to and authorize ANT staff to take photos of my child to be shared with family/guardians and promptly deleted from personal devices.NO, I do not consent to or authorize ANT staff to take photos of my child to be shared with family/guardians and promptly deleted from personal devices.
Signature*
Signature to acknowledge the exceptions to confidentiality:*
Animals as Natural Therapy programs operate rain or shine. In the case of inclement weather or natural disaster ANT staff will contact you at least 2 hours prior to your committed time to cancel.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, 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 will be led by PATH Intl. Certified Equine Professionals.
I understand that EAL programming at Animals as Natural Therapy is not a clinical mental health therapy. I understand there are no therapists on site.*
Date*

MonthDayYear
Date

Financial Agreement
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. 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.

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.

Financial Assistance 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.
Weekly (day of session)Bi-weeklyMonthlyOther (specify below)
Other option for scheduled recurring payments:
Absence Policy
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 at least 24 hours in advance if your child will be absent. Your child is considered “unexcused” if notice is given less than 24 hours prior to their session time. Exceptions will be made regarding emergency or sudden illness. If it is emergency or sudden illness please let us know at least 2 hours prior to your scheduled session time or we will mark you as unexcused.

We understand that emergencies do arise; however, an instructor fee will be charged for last minute cancellations & unexcused absences, equal to half the normal session fee ($50) for full-pay participant or full agreed-upon session fee for scholarship participants.

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.
I have read ANT's policies regarding billing and attendance, and I 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.*

Riding
Riding is not guaranteed in any program. Most ANT programming is groundwork and relationship based horsemanship - not riding. In the event that we will offer riding in a program, see the following for additional details.

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 riding purposes is 220 pounds for a balanced rider. Each horse has individual weight limitations based upon the horse’s weight, age and physical condition. Not all horses can manage the maximum weights listed below. 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 and physical abilities to determine if riding is a safe and appropriate activity based on available equine, staff and volunteers. All participant’s information will remain confidential.

• 220 lbs. for a well-balanced centered participant

• 150 lbs. for an unbalanced participant
For riding purposes only (optional): Provide participant weight. (I understand that if I choose not to disclose my child/dependent's weight or that the participant weighs more than the maximum 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.
Please provide your child/dependent's physician's name, phone number, and preferred medical facility
Please provide your health insurance company and policy number
In the event emergency medical aid/treatment is required due to illness or injury during the process of volunteering, or while being on the property of the agency, I authorize Animals as Natural Therapy to secure and retain medical treatment and transportation if needed. 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 below is unable to be reached.
Please make note of any medical information we should have on hand 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:

Participant Registration Form

Please contact Lindsey Polson with any questions regarding registration

Participant Agreements and Releases

Photo/Media Release

Equine Assisted Learning

Please note: EAL is not clinical mental health therapy. Sessions will be led by PATH Intl. Certified Equine Professionals.

Financial Agreement

Absence Policy

Riding

Authorization for Medical Treatment and Medical Information

Participant Medical History

Participant Demographics

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