Summer Camp Participant Registration Form

  • Participant Information

    Please be as thorough with your answers as possible. Our camps are designed for children (ages 6-12) of all abilities, and every camper is welcome here. Any information you provide is used solely to help our staff understand your child's individual needs and create the most supportive, enjoyable experience possible. It will never be used to determine eligibility, or to limit or deny participation. As a nonprofit organization, we rely heavily on grants that require us to report demographic information about our participants. Thank you for providing this information so that we can continue to provide our high-quality programs at the lowest cost possible. All information is protected by our confidentiality policy.

  • Registration Information

    • Please complete a separate form for each child you are enrolling.

     

    • The cost for Healing Reins Summer Camp is $250 per week, per child.
      - A non-refundable deposit of $50 per week is due at the time of registration. Please make sure the correct number of deposits is selected in the payment field.
      - The remaining balance of $200 per week is due by May 31.

     

    • Healing Reins is offering a limited number of scholarships for Summer Camp.
      - If you plan to apply, please submit your application by May 15.
      - Families registering multiple children only need to complete one scholarship application per household.
      - You can find the scholarship application HERE.
  • Person Completing This Form is the:
  • Were you referred to Healing Reins by a person, organization or agency?
  • Child's Date of Birth*
     / /
  • Does the participant have an IEP, IFSP or 504 plan on file with their school (if applicable)?*
  • Participant's Gender Identity (check all that apply and/or use the "Other" field):*

  • Please share the participant's pronouns:

  • What is the Participant's racial/ethnic background? (check all that apply)*

  • Please describe the participant's experience with horses:
  • Does the participant experience any sensory processing sensitivity, disorders, or disabilities, in the following areas:
  • Behavioral Health Issues. Does the participant have a history of, or are they currently experiencing, any of the following:*

  • First Aid & Emergency Contact Information

  • Does participant carry an EpiPen?*
  • Does participant use an inhaler?*
  • Does participant have a history of seizures?*

  • Please note: Healing Reins automatically calls 911 in cases of seizures lasting over 2 min. or multiple seizures in a short time frame

  • Date of last seizure
     / /

  • Health & Cognitive Information

  • Is the participant proficient in the following areas? Please check all that apply: *
  • Educational/Cognitive *
  • Social*
  • Language*
  • Follows simple directions*
  • Attention to task*
  • Frustration tolerance*
  • Problem solving*
  • Learning Style *

  • Photo & Publicity Release

    Do you consent to and authorize the use and reproduction by Healing Reins of any and all photographs and any other audio/visual materials for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
  • Photo & Publicity Release*

  • Participant Agreement, Consent & Release

  • CONSENT FOR EMERGENCY MEDICAL TREATMENT: In the event of an emergency, if medical aid/treatment is required due to illness or injury while participating in the services of, or while being on the property of, Healing Reins Equine Assisted Services, an Oregon non-profit corporation, I authorize Healing Reins to secure and retain medical treatment and/or transportation if needed. This authorization includes any treatment deemed necessary by a treating health care professional and includes, but is not limited to, x-ray, surgery, hospitalization, and medication. In addition, I authorize Healing Reins to release my/my child/my ward’s records to any individual involved in medical treatment and/or necessary transportation. LIABILITY RELEASE: Under Oregon Law, 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 participating in equine activities, pursuant to section 30.691, Oregon Revised Statutes. I would like to participate in Healing Reins' program. I acknowledge the risks and potential for risks in riding and working with horses. However, I feel that the possible benefits to myself/my child/my ward are greater than the risks assumed. Intending to be legally bound, for myself and my heirs, assigns and legal representatives, I hereby forever waive and release any and all claims, whenever arising, against Healing Reins and their respective directors, officers, members, employees, agents and representatives arising from, or relating in any way to my/my child’s/my ward’s participation in any Healing Reins Equine Assisted Services or presence on the Healing Reins property generally.

  • Please confirm the weeks you have signed up for

  • My Products*

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