Grounds Program Seizure Disclosure Statement

Name

First NameLast Name

Additional medical conditions:

Allergies:

All participants with a history of any seizures must provide the following information:

Type of seizure could include, but not limited to the following:

Generalized Tonic Clonic Seizures (Grand Mal) - includes loss of consciousness, stiffening of body (tonic) followed by jerking of the muscles (clonic)
Myoclonic Seizures - consciousness is not affected, brief but intense muscle jerks usually involving the upper body. May sometimes lead to Tonic Clonic Seizures.
Tonic Seizures (Drop Attacks) - sudden, brief stiffening of the whole body, usually result in falling, no loss of consciousness
Clonic Seizures (Drop Attacks) - sudden, brief loss of muscle tone throughout the body. Body goes lim and person will collapse, no loss of consciousness.

Type of Seizures:

Typical Aura (pre-seizure sensations or behaviors):

Typical motor activity during seizures:

Frequency of seizures (how many per week, month, etc)

Average duration of seizures:

Any known triggers for seizure activity:

Any routine medications taken and any side effects noted (i.e. drowsiness and photosensitivity):

Treating physician for seizures:

Any medications or special procedures to prevent or control seizures on an as needed basis, including nasal spray, suppository, VNS magnets, etc. to be administered by parent / guardian / caregiver:

SEIZURE POLICIES

1. Participants with any history of seizures must submit a Seizure Disclosure Statement signed by a guardian prior to participating in any CTRH programs.

2. If a participant has a history of seizures, an adult responsible for that participant will be asked to stay in sight of the participant at all times whil participating in CTRH programming.

3. CTRH Staff must be notified of any new seizure activity, including any changes in frequency or type of seizures. Failure to notify CTRH staff may result in dismissal from the program.

4. Any medications or procedures (including magnets for VNS) that must be administered to participant to prevent to control seizures must be administered by an adult responsible for that participant. Medications and / or procedures will not be administered by CTRH Staff.

5. CTRH instructors working directly with a participant with a known history of seizures will have access to the CTRH Seizure Disclosure Statement for the participant. Volunteers working with a participant with a history of seizures will be made aware of pertinent information by the instructor for the participant's safety.

If there is a history of seizures, a Seizure Disclosure Statement has been signed and the information disclosed above is accurate and complete to the best of my knowledge. I have read the Seizure Policies above and understand and agree with all the policies listed. I further understand that it is my responsibility to disclose any new seizure activity or any change in frequence of seizures for the duration of my participant in any CTRH program and that failure to do so could result in significant risk and / or injury to myself, my participant, CTRH Staff, volunteers, and horses and could result in dismissal from the program.

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