Participant’s Application and Health History
Please copy this page and place it in Word for a working format
GENERAL INFORMATION
Participant’s Name:
DOB Age: Height: Gender: M F
Address:
Phone: Email:
Employer/School:
Address:
Phone:
Parent/Legal Guardian:
Address (if different from above):
Phone:
Referral Source:
Phone:
How did you hear about the program?
HEALTH HISTORY
Diagnosis: Date of Onset:
Please indicate current or past special needs in the following areas:
Vision Y N Comment:
Hearing Y N Comment:
Sensation Y N Comment:
Communication Y N Comment:
Heart Y N Comment:
Breathing Y N Comment:
Digestion Y N Comment:
Elimination Y N Comment:
Circulation Y N Comment:
Emotional/Mental Health Y N Comment:
Behavioral Y N Comment:
Pain Y N Comment:
Bone/Joint Y N Comment:
Muscular Y N Comment:
Thinking/Cognition Y N Comment:
Allergies Y N Comment:
MEDICATIONS (include prescription, over-the-counter; name, dose and frequency)
PHYSICAL FUNCTION (Describe your abilities/difficulties in the following areas-include required or equipment needed. .i.e. Mobility skills such as transfers walking, wheelchair use, driving/bus riding)
PSYCHO/SOCIAL FUNCTION (i.e. Work/school including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc.)
GOALS (i.e. Why are you applying for participation? What would you like to accomplish?
SIGNATURE: _______________________ DATE: __________
Client Parent or Legal Guardian
PHOTO RELEASE
I ( ) DO
I ( ) DO NOT
Consent to and authorize the use and reproduction by Partners Therapeutic Horsemanship of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
SIGNATURE: _______________________ DATE: __________
Client Parent or Legal Guardian
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Partners Therapeutic Horsemanship
Authorization for Emergency
Medical Treatment Form
( ) Participant ( ) Staff ( ) Volunteer
Name: DOB: Phone:
Address:
Physician’s Name: Preferred Medical Facility:
Health Insurance Company: Policy #:
Allergies to medications:
Current medications:
In the event of an emergency, contact:
Name: Relation: Phone:
Name: Relation: Phone:
Name: Relation: Phone:
In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize Partners Therapeutic Horsemanship to:
1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
Consent Plan
This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life saving” by the physician. This provision will only be invoked if the person(s) above is unable to be reached.
Date: _____________ Consent Signature: ________________________________
Client, Parent or Legal Guardian
Signed in the presence of Center Staff
Non-Consent Plan
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency
( ) Parent or legal guardian will remain on site at all times during equine assisted activities
( ) In the event of emergency treatment/aid is required, I wish the following procedure to take place:
Date: _____________ Consent Signature: ________________________________
Client, Parent or Legal Guardian
Signed in the presence of Center Staff
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Letter to Health Care Provider
Date:
Dear Health Care Provider:
Your patient, ________________________________ is interested in participating in supervised equine activities.
In order to safely provide this service, our center requests that you complete/update the attached medical history and Physician’s Statement Form. Please note that the following conditions may suggest precautions and contraindications to equine activities. Therefore, when completing this form, please note whether these conditions are present, and to what degree.
Orthopedic Medical/Psychological
Atlantoaxial Instability-include neurologic symptoms Allergies
Coxa Arthrosis Animal Abuse
Cranial Deficits Cardiac Condition
Heterotopic Ossification/Myositis Ossificans Physical/Sexual/Emotional Abuse
Joint subluxation/dislocation Blood Pressure Control
Osteoporosis Dangerous to self or others
Pathologic Fractures Exacerbations of medical conditions (RA, MS)
Spinal Joint Fusion/Fixation Fire Settings
Spinal Joint Instability/Abnormalities Hemophilia
Medical Instability
Neurologic Migraines
Hydrocephalus/Shunt PVD
Seizure Respiratory Compromise
Spina Bifida/Chiari II malformation/ Recent Surgeries
Tethered Cord/Hydomyelia Substance Abuse
Thought Control Disorders
Other Weight Control Disorders
Age – under 4 years
Indwelling Catheters/Medical Equipment
Medications-ie photosensitivity
Poor Endurance
Skin Breakdown
Thank you very much for your assistance. If you have any questions or concerns regarding this patient’s participation in equine assisted activites, please feel free to contact the center at (619) 469-9544.
Sincerely,
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Partners Therapeutic Horsemanship
Participant’s Medical History & Physician’s Statement
Participant:____________________ DOB:__________ Height:_________ Weight:__________
Address:_______________________________________________________________________
Diagnosis:______________________________________ Date of Onset:___________________
Past/Prospective Surgeries:_________________________________________________________
Medications:____________________________________________________________________
Seizure Type:________________________ Controlled: Y N Date of Last Seizure:___________
SpecialPrecautions/Needs:_________________________________________________________
Mobility: Independent Ambulation Y N Assisted Ambulation Y N Wheelchair Y N
Braces/Assistive Devices:__________________________________________________________
For those with Down Syndrome: AtlantoDens Interval X-rays, date:_________ Result: + --
Neurologic Symptoms of Atlanto Axial Instability:______________________________________
Please indicate current or past special needs in the following systems/areas, including surgeries:
Auditory Y N Comments:
Visual Y N Comments:
Tactile Sensation Y N Comments:
Speech Y N Comments:
Cardiac Y N Comments:
Circulatory Y N Comments:
Integumentary/Skin Y N Comments:
Immunity Y N Comments:
Pulmonary Y N Comments:
Neurologic Y N Comments:
Muscular Y N Comments:
Balance Y N Comments:
Orthopedic Y N Comments:
Allergies Y N Comments:
Learning Disability Y N Comments:
Cognitive Y N Comments:
Emotional/Psychological Y N Comments:
Pain Y N Comments:
Other Y N Comments:
To my knowledge, there is no reason why this person cannot participate in supervised equine activities. However, I understand that the NARHA center will weigh the medical information above against the existing precautions and contraindications. I concur with the review of this person’s abilities/limitations by a licensed/credentialed health professional (e.g. PT, OT, SLP, Psychologist, etc.) in the implementation of an effective equine activity program:
Name/Title:_______________________________________________ MD DO NP PA Other________
Signature:_________________________________________________________ Date: _____________
Address:______________________________________________________________________________
Phone: ( ) _____________________________________________ License/UPIN _________________ Number:______________________________________________________________________________
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Partners Therapeutic Horsemanship
AGREEMENT FORM FOR FULL ASSUMPTION OF RISK
AND RELEASE OF ALL LIABILITY
I, the undersigned, am of legal adult age and of sound mind do for myself, or on behalf of my child or legal ward, or other minor listed below, for whom I hereby attest to accepting full responsibility for (hereinafter all inclusively “the rider”), hereby voluntarily request to participate in the horseback riding activities directed by Partners Therapeutic Horsemanship Inc.
I, and/or the rider will ride and work with either a horse provided by Partners, my own horse, or a horse provided by a third party. I understand that I and/or the rider is responsible for all bodily injury and or property damage which I, and/or the rider, and/or the rider’s horse should cause or receive either on the premises of Donald and Margaret Bright, Lone Oak Ranch and the Bright Family Trust dated Jan. 16, 1989 or any other property, including any trails, while accompanying other horses or riding alone or receiving instruction. Furthermore, I accept all responsibility and liability for any incident involving the rider and/or the rider’s horse with any other rider, horse, individual or property.
I understand that horseback riding is a dangerous activity and that there are dangers from even being near a horse and that any horse, even the most gentle, can be provoked or frightened and as a result act or react in a dangerous or unpredictable manner. We agree not to touch, pet or feed any horses or enter the horse’s pens without the horses owners’ permission or to provoke or otherwise influence our horse or the horse of another rider at any time as this can be very dangerous.
I understand that horses are animals and as such are unpredictable by nature; that when frightened, angry, under stress, or for no reason at all, a horse’s natural instincts are to move, shake, bolt, jump forward or sideways, to run away from danger, to kick, to buck, to rear up in front, or to bite. Any horse may bite or kick me or another rider or horse. I understand that horses are extremely heavy and powerful and that if I fall to the ground the fall distance will be generally 4 to 6 feet or if a horse lays down on me that the weight may be between 500 to 2,000 pounds. I understand that any or all of the horse activities directed by partners Therapeutic Horsemanship, Inc., or their representatives, may cause myself and/or the rider serious permanent injury or death and I and/or the rider agree to participate in this activity willingly and voluntarily.
I hereby agree not to bring any suit against Partners Therapeutic Horsemanship, Inc., or their representatives, their successors, assigns, agents, affiliates, owners, employees, officers, member or Board of Directors, advertisers, sponsors or supporters and volunteers for any reason at any time now or in the future for any injury, damage, or incident which may occur as a result of my participation in any activity offered and provided by or affiliated with Partners Therapeutic Horsemanship, Inc., or their representative. I and the rider hereby for ourselves, heirs, administrators, assigns and representatives completely release, indemnify, hold harmless and discharge the owners, operator, sponsors, agents, associates and employees of Partners Therapeutic Horsemanship, Inc., or their representatives, and their respective agents, associates, and all other participants of and from Partners Therapeutic Horsemanship, Inc. equestrian activities. I furthermore agree to reimburse Partners Therapeutic Horsemanship, Inc. upon demand for any and all expenses incurred as a result of any action, legal or otherwise, that I, my heirs, administrators, assigns, representatives or agents or those of the rider may initiate against Partners Therapeutic Horsemanship, Inc., and/or their agents, representatives associates or other participants nor or in the future.
I understand Donald and Margaret Bright, Lone Oak Ranch and the Bright Family Trust dated Jan. 16, 1989 are a completely separate entity from Partners Therapeutic Horsemanship, Inc. and hereby agree not to bring any suit against Donald and Margaret Bright, Lone Oak Ranch and the Bright Family Trust dated Jan. 16, 1989, their clients or client’s horses, their successors, assigns, agents, affiliates, employees, officers, members or Board of Directors, advertisers, sponsors or supporters and volunteers for any reason at any time now or in the future for any injury, damage, or incident which may occur as a result of my participation in any activity offered and provided by or affiliated with Partners Therapeutic Horsemanship, Inc. I and the rider hereby for ourselves, heirs, administrators, assigns and representatives complete release, indemnify, hold harmless and discharge the owners, operator, sponsors, agents, associates, and employees of Partners Therapeutic Horsemanship, Inc., their respective agents, representatives, associates and all other participants of and from Partners Therapeutic Horsemanship, In., and Donald and Margaret Bright, Lone Oak Ranch and the Bright Family Trust dated Jan. 16, 1989. I furthermore agree to reimburse Partners Therapeutic Horsemanship, Inc., Donald and Margaret Bright, Lone Oak Ranch and the Bright Family Trust dated Jan. 16, 1989 upon demand for any and all expenses incurred as a result of any action, legal or otherwise, that I, my heirs, administrators, assigns, representatives or agents or those of the rider may initiate against partners Therapeutic Horsemanship, Inc., Donald and Margaret Bright, Lone Oak Ranch and the Bright Family Trust dated Jan. 16, 1989 and/or their agents, representatives, associates or other participants now or in the future.
In the event that nay of the terms or conditions of this document is held to be illegal, unenforceable or invalid by any court of competent jurisdiction, the legality , validity and enforceability of the remaining terms or conditions shall not be affected thereby.
I acknowledge that I have read, understand, agree and accept all provisions, conditions, warnings, and dangers as stated. I understand this agreement and assumption of risk and liability release document and I assume any and all risks inherent in all horse related activities whether stated herein or not and that I completely release, indemnify and hold harmless Partners Therapeutic Horsemanship, Inc., and any other affiliate entity form any and all liability or responsibility for any incident, accident, damage injury, illness or loss to the rider, rider’s horse, the undersigned or to any family member, spectator or guest accompanying the undersigned or in the care of the undersigned.
I further agree and hereby stat under penalty of law that all information provided on this document by the undersigned is true and correct. I further understand and agree that all monies, if any, paid by me, the undersigned or the rider to Partners Therapeutic Horsemanship, Inc., are not refundable in whole or in part for any reason whatsoever. I agree to pay Partners Therapeutic Horsemanship, Inc., in full, at their current rates, prior to riding or beginning work with a horse, for the opportunity to learn horse care and management and riding skills. I agree not to stop or dispute payment for any reason.
Print Responsible Adult’s Name (Parent, Guardian, Caregiver or Volunteer):
_____________________________________________________________________________________
Responsible Adult’s Signature:
_________________________________________________________
Student Rider’s or Volunteer (under 18 Name: ______________________________ Age: _____________
Phone Numbers: Home: _____________________ Cell __________________ Work ______________
Email: ________________________________________________________________________________
Address: ______________________________________________________________________________
Please list any specific concerns (health or otherwise), conditions, learning disabilities, etc.
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