Wings of Hope Equitherapy- New Client Application 24-25

New Client Application

Wings of Hope Equitherapy
Participant Name:*
First and Last Name
Preferred name if different
Gender*

MaleFemale
Ethnicity*

Asian/Pacific IslanderBlack or African AmericanHispanic or LatinxNative AmericanWhite Non- HispanicTwo or More RacesOther
DOB*
Current Age*
Height*
Weight*
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:*

VisonHearingCommunicationSensoryHeartCirculationPulmonaryBoneJointMuscularThinking / CognitionEmotional / Mental HealthBehavioralOther
Please provide any comments pertaining to the above areas checked. *
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?
Scheduling & Availability

Wings of Hope has lessons Monday through Thursday morning, afternoon and evening. Please indicate your desired days and times for your availability. You are not committing to a specific day and time until your evaluation but this helps us to best understand your availability while looking at availability within our schedule.
My ideal day is blanks . My preferred time isblank* .
I am available*

MondayTuesdayWednesdayThursday
I am available*

10:00-12:0012:30-3:003:30-4:305:00-6:006:30-7:30
Family & Social Background

Everyone is influenced by many factors in their lives-school, culture, peers, family, etc. By providing additional information we are best equipped with a better picture of what is happening in the client's life. Please share as openly as you are comfortable.
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

MarriedDivorcedSeperatedSingleRemarried
Client's Father's Name, if applicable
If the client is a minor, please list father's name
Occupation
Father’s Marital Status

MarriedDivorcedSeperatedSingleRemarried
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.*

AggressiveAnxiousBullied by othersBullies othersConfidentCourageous/BraveDefiantDepressedDestructiveEasily frustratedFearfulFidgetyFollowerGrievingGood judgmentHappyHonestImpulsiveLeaderLittle self-controlLow self-esteemMoodyQuick to angerResponsibleSees things throughShyStubbornSuicidal attempts or thoughtsTantrumsTells lies/fibsWithdrawnOther
Emergency Medical Information

Name(s) of persons to contact in case of an emergency.
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.
Photo Media Release

I do or do not consent to and authorize the use and reproduction by Wings of Hope Equitherapy of any and all photographs, video, or any audio-visual materials taken of me or spoken/written testimonials for promotional material, education activities, social media or any other use for the benefit of Wings of Hope Equitherapy.
Consent*
Signature*

Clear
Date*

MonthDayYear
Date
Confidentiality Agreement

I understand that I may have access to confidential information, which may include, but is not limited to information about participants, volunteers, employees, staff, or stakeholders and other private information (such as records, conversations, financial information, access codes, and financial and statistical records). I will use confidential information only as needed by me to perform my duties on behalf of Wings of Hope Equitherapy ("WOH") I further agree not to disclose any of such confidential information without the express permission of the Executive Director of WOH, except as permitted by applicable law. I further agree that my obligations regarding confidential information under this agreement will continue after termination of my services with WOH.
Signature*

Clear
Date*

MonthDayYear
Date
Billing

Please disclose the guarantor responsible for payments and let us know if you will be self pay or if you will have another party or an agency full fill your payments.
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
Waiver and Release of Liability & Indemnity Agreement
Client's Full Name*
First and Last Name
Clients Date of Birth *

MonthDayYear
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*

Clear
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*

MonthDayYear
Date
Client Handbook

The following information, policies, and guidelines are designed to provide our participants and visitors with a safe, enjoyable, and beneficial experience at Wings of Hope.
I acknowledge I have received and read the 2024-2025 client handbook. *

Clear
Should be Empty:

New Client Application

Scheduling & Availability

Family & Social Background

Emergency Medical Information

Photo Media Release

Confidentiality Agreement

Billing

Waiver and Release of Liability & Indemnity Agreement

Client Handbook