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*
School youth is attending:
How did you hear about ANT?

Participant Agreements and Releases
Natural Disasters/Fire Protocol: In case of natural disaster (fire or earthquake), 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.*

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

Please select and sign ONE of the below options for photo/media release.
I hereby 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 promotional printed materials, educational activities or for any other use for the benefit of the program.
I 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 promotional printed materials, educational activities or for any other use for the benefit of the program.
Exceptions to Confidentiality

The privacy of your personal information is of utmost importance. ANT is compliant with current Federal and State of Washington laws. Federal and State laws limit confidentiality. ANT may use or disclose your personal health information when required or permitted to do so by law, or in the following situations:a) Duty to warn: Participant’s personal health information may be disclosed if we determine a need to alert an intended victim of a serious threat to their health or safety. For example, this may occur if participants reveal intentions to kill or harm another person. ANT is obligated to take necessary action to avert a serious threat to the health and safety of others.b) Danger to participant: Participant’s personal health information may be disclosed if ANT determines that participants may kill or seriously harm themselves or are in a dangerous situation. For example, this may occur if participants reveal that they are planning to attempt suicide. ANT is obligated to take necessary action to avert a serious threat to their health or safety.c) Child or elder abuse or neglect: Participant’s personal health information may be disclosed if they report or ANT reasonably suspects any child or elder abuse or neglect. For example, if participants reveal that they have physically harmed a child or have been harmed themself then ANT will need to notify Child Protective Services (CPS).d) Court order: Participant’s personal health information may be disclosed if ANT is presented with a court order to do so. For example, this may occur if participants have legal involvement, and a judge or law enforcement agency has called ANT to testify or release records.e) Crime against ANT or office premises: participant’s personal health information may be disclosed if they commit or threaten to commit a crime against ANT or within office premises. This includes damage to property.f) Other disclosures: participant’s personal health information may be disclosed for research when approved by an institutional review board, to military or national security agencies, coroner, medical examiners, and correctional institutions or otherwise as authorized by law. Participant’s personal health information may be disclosed to necessary parties involved if you file a legal or administrative claim against ANT’s business. Your identifying information may be disclosed to debt collection agency personnel if you fail to pay for ANT’s professional services by our agreed upon time period.g) ANT staff meets regularly with other appropriate professionals for consultation in order to improve our ability to be effective professionals. Periodically, we consult with other providers regarding issues specific to you or your child. When consulting with other professionals outside of Animals as Natural Therapy, no names ofthe client(s) are used in order to protect confidentiality, unless we have written consent of those clients or guardians.h) Animals as Natural Therapy’s Licensed Mental Health Clinicians and Mental Health Interns present client sessions and consult regularly with their Clinical Supervisor for clinical support. This Clinical Supervisor is bound by the same confidentiality rules as your mental health provider. Clinicians also occasionally share session information with the Mental Health team to ensure we are providing the highest level of care possible. Counseling interns may also be required to present client sessions for review with their graduate institution for educational purposes.
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. 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.
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, future sessions will be cancelled for the quarter and no further financial assistance will be given.
I have read this policy and understand that I am responsible for any necessary payment and my child/dependent’s attendance.*
Riding

Riding is NOT guaranteed in any program. Most programming is groundwork horsemanship-not riding. In the event that we will offer riding in a program, see the following for additional details. Maximum weights are listed below, but decisions regarding participation 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. Note: if a participant in a group session is above the maximum weight or is not physically capable of riding, the group will not have riding as an option.
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.
Emergency Contact #2 Name

First NameLast Name
Emergency Contact #2 Phone Number
Please enter a valid phone number.
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

Exceptions to Confidentiality

Equine Assisted Learning

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

Financial Agreement

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.