TCRC New Rider Packet

EQUINE EMPOWERMENT FOUNDATION
New TCRC Rider Registration and Emergency Contact Information
GENERAL INFORMATION:
Rider's Name (Participant's full name)

First Last
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address- Street, City, State & Zip Code
Cell Phone:
Text notifications for cancellations or important informationFormat: (000) 000-0000.
E-mail Address:
Please include an email address that you check frequently. Email is a convenient and inexpensive way for us to contact you. We would like to use it to alert you of cancellations, session information and program events.
Height (ft/in) & Weight (lbs)
Gender: Male/Female
School/ Employer
School/ Employer's Phone:
Format: (000) 000-0000.
Previous riding experience?
How did you come to know about our program?
Mother or Legal Guardian Information:
Name:

First NameLast Name
Cell Phone:
Format: (000) 000-0000.
Place of Employment:
Occupation:
E-mail Address:
Please include an email address that you check frequently.
Best way to contact you:
Father or Legal Guardian's Information:
Name:

First NameLast Name
Cell Phone:
Format: (000) 000-0000.
E-mail Address:
Please include an email address that you check frequently.
Occupation:
Place of Employment:
Best way to contact you:

Please indicate current or past needs in the following areas (Check Yes or No. If "Yes", please add comments):

Rows	Yes	No	Comments
Vision
Hearing
Sensation
Communication
Heart
Breathing
Digestion
Elimination
Circulation
Emotional/Mental Health
Behavioral
Pain
Muscular
Thinking/Cognition
Bone/Joint
Allergies

New TCRC Rider Registration and Health History - Page 2
BILLING INFORMATION

(Individual Responsible for Payment):
Service Coordinator's Name:

First NameLast Name
Service Coordinator's Phone:
Format: (000) 000-0000.
Service Coordinator's Email
example@example.com
Authorizations
UCI #
Caregiver name (if applicable):
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Primary Emergency Contact
Phone:
Format: (000) 000-0000.
Relation:
Physician's Name:
Preferred Medical Facility:
Phone:
Format: (000) 000-0000.
Health Insurance Company:
Policy #
Health History
Allergies:
Current Medications:
Significant Medical History:
Diagnosis:
Date of Onset:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
**Certain Medical Conditions or Indicators under Health History may require a Medical Clearance by your Primary Care Physician or Specialist prior to participating in our programs**

NO CALL, NO SHOW POLICY
When you enroll at EQUINE EMPOWERMENT FOUNDATION, you are scheduled on a regular basis and a horse is prepared prior to each lesson. We also schedule staff and volunteers to meet the needs of the class (both in individual and group lessons).
LESSON RATES

30-Minute Private Lesson - $100.
45-Minute Private $125
50-Minute Group Lesson $100
If you wish to cancel your ride with us you must give us 24 hr prior notice or full payment will be charged. Everyone feels they have a valid reason for us to waive the cancellation fee when a ride is cancelled for social, family, health or business reasons, but there can be NO exceptions to the rule.
If you are more than 10 minutes late for your scheduled lesson you will NOT be able to ride. Please arrive on time. If you are consistently late we will need to discuss a different time that is more suitable.
All No Call/NO Show absences will be charged the full lesson fee. After three (3) No Call/No Shows, you will be taken off the calendar.
For lessons cancelled with 24 hour prior notice, we allow for one make-up lesson a month.
Please understand that we are a start-up 501(c)(3) nonprofit and have not received significant funding or grants yet; every scheduled lesson is what pays the bills to support the horses and afford our instructors. We truly appreciate your understanding and support!
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND AGREE WITH EEF'S NC/NS POLICY
Release of Liability
I acknowledge that horseback riding, barn activities, and other equine activities involve inherent risks, including the risk of serious injury or death. I freely and voluntarily assume those risks and, to the fullest extent permitted by law, release and hold harmless TCRC, its staff, volunteers, and affiliates from any liability arising from my participation.
I acknowledge and accept the risks and release TCRC, its staff, volunteers, and affiliates from liability
Rider's Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Rider Signature
Parent 1/Legal Guardian Sign & Date
Parent 2/Legal Guardian Sign & Date
Date:

MonthDayYear
Date:

MonthDayYear
Type a question
Should be Empty:

EQUINE EMPOWERMENT FOUNDATION

New TCRC Rider Registration and Emergency Contact Information

GENERAL INFORMATION:

Mother or Legal Guardian Information:

Father or Legal Guardian's Information:

New TCRC Rider Registration and Health History - Page 2

BILLING INFORMATION

Health History

NO CALL, NO SHOW POLICY

Release of Liability