PARTICIPANT UPDATE FORM
Hope Haven Therapeutic Riding Centre
General Contact Information
Please fill out as much as possible in order to keep our records updated.
Participant Name
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Primary Contact Parent/Guardian
*
First Name
Last Name
Primary Contact Phone
*
-
Area Code
Phone Number
Primary Contact Email
*
example@example.com
Secondary Contact Parent/Guardian
First Name
Last Name
Secondary Contact Phone
-
Area Code
Phone Number
Secondary Contact Email
example@example.com
Support Worker Contact Name (if applicable)
First Name
Last Name
Support Worker Phone
-
Area Code
Phone Number
Support Worker Email
example@example.com
Please indicate contact will be accompanying participant to Hope Haven (if required).
Which contact will be handling the billing.
Current Health Status
Height
Weight (180lbs weight restriction for riders)
*
Please list any medical diagnoses
Examples: ADHD, Down Syndrome, ASD, Seizure Disorder, MS
Please describe any PHYSICAL challenges
Physical challenge = difficulties with mobility, strength, range of motion, endurance, coordination, vision
Please describe any COGNITIVE challenges
Cognitive challenge = difficulties with mental activities such as learning, memory, understanding, attention, appropriate language use
Please describe any EMOTIONAL challenges
Emotional challenge = difficulty managing change, anxietiy, depression, self esteem and worth, empathy towards others, daily motivation
Current Medications
Allergies
History of Seizures?
*
Yes
No
Seizures: last occurrence, type of seizure, related medications
Signature of Participant if >18 or Parent/Gaurdian
*
Date Signed
-
Month
-
Day
Year
SF ID
Submit
Should be Empty: