Wings of Hope Equitherapy- New Client Application

Participant Name:*

First and Last Name

Preferred name if different

Gender*

MaleFemale

Ethnicity*

DOB*

Current Age*

Height*

Weight*

Eligibility for mounted services requires that clients must be must be 199lbs or less.

Address*

Address

Street Address Line 2

CityState

Zip

Phone*

Alternate Phone

Please provide a secondary phone number if applicable

Email Address*

example@example.com

What is your preferred method of contact?*

Phone callText messageEmail

May we communicate via text message?*

YesNo

Parent/Legal Guardian name, if a minor

First and Last Name

Parent/Legal Guardian phone

Caregiver Name

Do you have a caretaker, attendant, family member, etc. who will be involved in your transportation, communication, etc.?

Caregiver phone

Do you have a history of seizures?*

Please list all diagnosis as it pertains to equine assisted services and the date of onset and give current health information and a brief health history as it pertains to equine assisted services.*

Please provide us with pertinent health history information that may impact participation in activities provided by Wings of Hope.

Please indicate any current or past special needs in the following areas, check all that apply:*

Please provide any comments pertaining to the above areas checked. *

Do you have any medical implants, and why? (screws, rod, button, bag, devices, etc.) *

Do you have a program preference?*

Mounted (horseback riding)Ground based (non mounted)No preference

What are your goals for therapeutic horsemanship?*

Please state at least 3 goals you would like to accomplish in therapeutic horsemanship. What are your desires or expectations for partnering with a horse?

Do you have any physical limitations?*

Please describe any assistance you may need physically or list any additions, omitions, or changes in adaptive or durable medical equipment.

Please describe any behavioral challenges or concerns.*

Feel free to describe any additional information that would be helpful.

Please describe the client's abilities and challenges.*

How can Wings of Hope help with tools to manage these while present in or away from the barn?

To help us better understand your availability does the client participate in any of the following:*

To help us better understand your activities does the client participate in any of the following:*

My ideal day is blank . My preferred time isblank* .

I am available*

MondayTuesdayWednesdayThursday

I am available*

Please describe the clients likes, dislikes, interests, concerns, etc. *

i.e., work/school including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc.

Client's Spouse's Name, if applicable

Is the client married?

Spouse’s Occupation

Client's Mother's Name, if applicable

If the client a minor, please list mother's name.

Mother’s Occupation

Mother’s Marital Status

Client's Father's Name, if applicable

If the client is a minor, please list father's name

Occupation

Father’s Marital Status

Who lives in the client's home or list any siblings and their ages, or signfigant people in their lives? *

We ask for this information to better serve you and make meaningful connections. Understanding the backgrounds and relationships of those living in your home or involved in your life helps us to engage in relevant conversations

Check all that apply to the client.*

Name of 1st Person To Contact*

First and Last Name

Relationship*

Phone*

Name of 2nd Person To Contact *

First and Last Name (In the event the 1st person was not reached)

Relationship*

Phone*

Please list any allergies or additional helpful information during an emergency or for first responders. *

Please put N/A if no additional information is needed.

Consent*

Signature*

Date*

Date

Signature*

Date*

Date

Payments will be full filled by *

Guarantor Name*

Guarantor First and Last Name or Agency Contact Name

Relationship to Client*

Phone*

Email*

example@example.com

Preferred Method of Payment*

Weekly by CheckMonthly by CheckMonthly by Card via InvoiceOther

Client's Full Name*

First and Last Name

Clients Date of Birth *

Date

Client's Age*

Is the client a minor?*

YesNo

Full Name of Minor Child

Full Name of Legal Guardian of Minor Child

Legal Guardian First and Last Name

I individually or on behalf of the named minor for and in consideration of the opportunity to participate in or on Wings of Hope Equitherapy ("WOH") property and facilities and/or to work with or ride WOH's horses do hereby release and agree to indemnify, defend, and hold harmless WOH and its board of directors, therapists, aides, volunteers, employees, agents or representatives as set forth below: I understand and acknowledge that working with and riding a horse involves inherent risks and dangers, which could result in personal injury or death. I/we acknowledge the risks and dangers of working with and riding a horse, and based upon my own analysis, I have made the decision for myself and/or my minor child to participate in the equine services provided by WOH.

UNDER TEXAS LAW (CHAPTER 87, CIVIL PRACTICE AND REMEDIES CODE) AN EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISK OF EQUINE ACTIVITIES.

WAIVER AND RELEASE OF LIABILITY I HEREBY EXPRESSLY WAIVE AND RELEASE ANY CLAIM FOR COMPENSATION OR LIABILITY

ARISING OUT OF ANY PERSONAL INJURY, DEATH, OR PROPERTY DAMAGE THAT I, MY MINOR CHILD, OR MY WARD MAY SUSTAIN ON WOH'S PROPERTY OR FACILITIES OR IN CONNECTION WITH PARTICIPATING IN ANY ACTIVITIES CONDUCTED BY WOH, REGARDLESS OF WHETHER SUCH PERSONAL INJURY OR DEATH IS CAUSED IN WHOLE OR IN PART BY THE ACTS OR OMISSIONS OR NEGLIGENCE OF WOH OR IT'S BOARD OF DIRECTORS, THERAPISTS, AIDES, VOLUNTEERS, EMPLOYEES, AGENTS OR REPRESENTATIVES"RELEASEES")

INDEMNITY AGREEMENT I FURTHER AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS WINGS OF HOPE EQUITHERAPY AND, IT'S BOARD OF DIRECTORS, THERAPISTS, AIDES, VOLUNTEERS, AGENTS AND REPRESENTATIVES ("INDEMNITEES") FROM ANY CLAIM FOR PERSONAL INJURY, DEATH, OR PROPERTY DAMAGE THAT I, MY MINOR CHILD, OR MY WARD MAY SUSTAIN ON WOH'S PROPERTY OR FACILITIES OR IN CONNECTION WITH PARTICIPATING IN ANY ACTIVITIES CONDUCTED BY WOH, REGARDLESS OF WHETHER CAUSED IN WHOLE OR IN PART BY THE ACTS OR OMISSIONS OR NEGLIGENCE OR FAULT OF INDEMNITEES.

I understand that WOH, its Board of Directors, therapists, aides, volunteers, employees, agents, and/or representatives Guarantors, Instructors, Volunteers, and/or Staff members will not be legally liable for any property damage, personal injuries or death that I or, my minor child may sustain in connection with equine activities regardless of any fault or negligence on the part of Indemnitees or Releasees.

I understand that the waiver and release of liability and indemnity agreement extend to any and all activities conducted on WOH's property and facilities or in connection with activities conducted by WOH in which I and/or my child may participate now or in the future.

I represent to WOH that I am the parent or legal guardian of the minor child listed and am legally authorized to sign this agreement and bind myself and the minor child to this agreement.

Name of Minor Child

Participant, Parent/Legal Guardian Signature*

Participant, Parent/Legal Guardian Printed Name*

I represent to WOH that I am the parent or legal guardian of the minor child listed above and legally authorized to sign this agreement and bind myself and the minor child to this agreement

Today's Date*

Date

I acknowledge I have received and read the 2024-2025 client handbook. *

New Client Application

Scheduling & Availability

Current Wings of Hope Schedule Availability

Family & Social Background

Emergency Medical Information

Photo Media Release

Confidentiality Agreement

Billing

Waiver and Release of Liability & Indemnity Agreement

Client Handbook