hohparticipantforms

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HEROES ON HORSEBACKPhone: 843-757-5607 Fax: (843) 757-5612

Participant Registration and Photo Release Form

Participant Name: Date of Birth: Sex: M F

Address: City: State / Zip:

Home Phone: Cell Phone: E-mailL

Parent (custodial) or

Gaurdian:

Address if different: Phone if different:

School or Programs presently attending:

Please describe previous experience with horses / riding (no experience isrequired):

I would like to register for the Following Session: Bluffton Site:_______# weeks, Beginning Date: _________

Beaufort /St. Helena Site: _______# weeks, Beginning Date: ________Sessions will not be canceled for inclement weather; other equine assisted learning

activities will be offeredPhoto Release

I consent I do not consent

to and authorize the use and reproduction by Heroes on Horseback of any and allphotographs and any other audio-visual materials taken of me for promotionalmaterial, educational activities, exhibitions or for any other use for the benefit ofthis program.Please sign below only if you checked I do consent:

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Date: _________________ Signature:___________________________________________________

Client, Parent/Guardian

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Authorization of Emergency Medical Treatment Form

In the event emergency medical aid/treatment is required due to illness or injury duringthe process of receiving services, or while being on the property of the agency, I authorizeHeroes on Horseback to Secure and retain medical treatment and transportation if needed.Release client records upon request to the authorized individual or agency involved in themedical emergency treatment.Participant Name: Phone: Phone:

Address: City: State / Zip:

If I cannot be reached Contact: Phone: Phone:

Alternate Emergency Contact: Phone: Phone:

Physicians Name: Phone:

Preferred Medical Facility:

Health Insurance Company: Policy #:

Consent PlanThe authorization includes x-ray, surgery, hospitalization, medication and any treatmentprocedure deemed life saving by the physician. This provision will only be invoked if theperson below is unable to be reached.

Consent Signature: (Client, Parent or Gaurdian): Date:

Please Print Name: Phone #:

Non-Consent PlanI do not give my consent for emergency medical treatment/aid in the case of illness orinjury during the process of receiving services, or while being on the property of theagency. In the event emergency treatment/aid is required, I wish the following proceduresto take place:

Consent Signature: (Client, Parent or Gaurdian): Date:

Please Print Name: Phone #:

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Client Medical History & Physicians Statement( PAGE 1 OF 2 )

Participant Name: Date of Birth:

Sex: Race: Height Weight:

Name / Address of Guardian: Tetanus Shot: YESNODate:

Diagnosis: Date of Onset:

Medications:

Please indicate if patient has a problem and/or surgical history in any of the following areas:AREA YE

SN

OCOMMENTS AREA YE

SNO

COMMENTS

Auditory Muscular

Visual IndependentAmbulation

Speech Crutches

Allergies Braces

Cardiac Wheelchair

Circulatory Neuroligical

LearningDisability

Orthopedic

MentalImpairment

Pulmonary

PsychologicalImpairment

Other

Seizures Type: Controlled:

Date of Last Seizure:

** Please complete required information on page 2 for SEIZURE patients ** See Page 2 forlist of precautions and contraindications

ATLANT O-AXIAL INSTAB ILIT Y ASS ES SMENT FOR PATIENTS WIT H DOWN SYN DROMIf the patient has Down syndrome a full radiological examination establishing the absence of Atlanto-axiInstability is REQUIRED before they may participate in equestrian activities which, by their nature, mayresult in hyperextension, radical flexion or direct pressure on the neck or upper spine.Yes

No

Has an x-ray evaluation for atlanto-axial instability been done? DATE of X-RAY ___________If yes, was it positive for atlanto-axial instability? (positive indicates that the atlanto-dens intervis 5mm or more)

If this X-Ray is more than 1 year old Please state the result of the most recent visual examinationconducted within the past six months:

The client has not had a timely physical examination and so cannot at this point be socertified.

The clients annual physical examination reveals no symptoms of AAI The clients annual physical examination shows symptoms of AAI. Riding isCONTRAINDICATED.

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I have reviewed the attached list of conditions which may present precautions andcontraindications to therapeutic horseback riding on page 2, to my knowledge there is noreason why this person cannot participate in supervised equestrian activities:Physicians Signature: Date of EXAM:

Physicians Name (please print): Physicians Phone:

Address: Physicians FAX:

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Client Medical History & Physicians Statement( PAGE 2 OF 2 )

SEIZURE DISORDER PARTICIPANTS

NARHA (North American Riding for the Handicapped Association), recommends thefollowing information for NARHA Operating Centers for riders with seizure disorders.

Would you consider _________________________________________________________________sseizures to be:

Completely controlled Very well controlled Fairly controlled bymedication

Type of seizure:

Typical aura:

Typical motor activity during seizure:

Description of clients behavior during post-ictal state: Post-ictal state duration:

Specific directions as to what to do if a seizure should occur at Heroes on Horseback:

Physicians Signature Date:

INFORMATION FOR PHYSICIAN

The following conditions, if present, may represent precautions or contraindications to therapeutic horsebackriding. Therefore, when completing this form, please note whether these conditions are present and, if so, to whatdegree.

ORTHOPEDIC

Spinal FusionSpinal Instabilities/AbnormalitiesAlantoaxial InstabilitiesScoliosisKyphosisLordosisHip Subluxation and DislocationOsteoporosisPathologic FracturesCoxas ArthrosisHeterotopic OssificationOsteogenesis ImperfectaCranial DeficitsSpinal OrthosesInternal Spinal Stabilization

Disease

NEUROLOGIC

Hydorcephalus/shuntSpina bifidaTethered CordChiariI MalformationHydromyeliaParalysis due to Spinal CordInjurySeizure Disorders

SECONDARY CONCERNS

Behavior ProblemsAge under 2 yearsAge 2 - 4 yearsAcute exacerbation of chronic

disorder

Indwelling catheter

MEDICAL/SURGICAL

AllergiesCancerPoor EnduranceRecent SurgeryDiabetesPeripheral Vascular DiseaseVaricose VeinsHemophiliaHypertensionSerious Heart ConditionStroke (CerebrovascularAccident

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HEROES ON HORSEBACKBluffton, South CarolinaPhone (843) 757-5607

GENERAL ACTIVITY RELEASE, ASSUMPTION OF RISK and WAIVER OF

LIABILITY AGREEMENTThis document waives important legal rights. Read it carefully beforesigning.

I AGREE for myself, and/or my child, my/our administrators and assigns, in considerationfor my, and/or my childs, participation in Heroes on Horseback activity of the following:

I AGREE that I choose to participate voluntarily in Heroes on Horseback activities as arider, handler or spectator. I am fully aware and acknowledge that horse sports and Heroeson Horseback activities involve inherent dangerous risks of accident, loss, and seriousbodily injury including, but not limited to, broken bones, head injuries, trauma, pain,suffering or death (Harm). I fully understand that this release covers, but is not limitedto, inherent risks of an equine activity which mean a danger or condition that is an integralpart of an equine activity, including but not limited to, any of the following:

The propensity of an equine to behave in ways that may result in injury, death, or loss topersons on or around the equine;

The unpredictability of an equines reaction to sounds, sudden movement, unfamiliarobjects, persons, or other animals;

Hazards, including, but not limited to, surface or subsurface conditions;A collision with another equine, another animal, a person, or an object;The potential of an equine activity participant to act in a negligent manner that may

contribute to injury, death, or loss to the person of the participant or to other persons,including but not limited to, failing to maintain control over an equine or failing to act

within the ability of the participant.

I AGREE that I/my child/my ward would like to participate in the Heroes on Horsebackprogram. I acknowledge the risks and potential risks, however, I feel that the possiblebenefits to me/my child/my ward are greater than the risk assumed. I hereby, intending tobe legally bound for myself, my heirs and assigns, executors or administrators waive andrelease forever all claims for damages against Heroes on Horseback, its Board ofDirectors, instructors, therapists, aides, volunteers, employees, Running W Farm, SunshineStables and affiliated organizations for any and all injuries and/or losses I may sustainwhile participating in the Heroes on Horseback program including activities occurringoutside of the scope of the program itself, including, but not limited to transportation, caregiving, horse exercising etc.

By signing below, I ACKNOWLEDGE that I enter into this release after having read thesame, and place my signature hereto of my own free voluntary act and deed. By signingbelow, I represent to Heroes on Horseback that I fully understand its contents, that I do notneed any further explanation, and I waive any further explanation.

I AGREE to assume all risks of Harm to me and/or my child, and specifically agree tothe SOUTH CAROLINA LIABILITY LAWregarding equine/ farm animal activity liability: Under South Carolina Law, an equineactivity sponsor or equine professional is not liable for an injury to or the death

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of a participant in an equine activity resulting from an inherent risk of equineactivity, Pursuant to Article 7, Chapter 9 of Title 47, Code of Laws of SouthCarolina, 1976.

ACCEPTED BY: (if under the age of 18 years old, there must be a legalguardian signature below)

PARTICIPANT Signature / Legal GuardianSignature(s):

VOLUNTEER Signature / Legal GuardianSignature(s):

Print Participant Name / Legal GuardianName(s):

DATE:

Volunteer Signature / Legal Guardian Signature(s):

DATE:

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Heroes on Horseback

TUITION ASSISTANCE APPLICATION

It is the policy of Heroes on Horseback that, as far as funds are available, a qualified rider should not be

prevented from riding because of inability to pay.However, each rider should be encouraged to pay for the servicewithout creating hardship. All information provided will be considered confidential. Tuition for a six week session is$150I would like to apply for tuition assistance in order to participate in the Heroes on Horseback program for the:

Winter 2008 Session Spring 2008 Session Summer 2008 Session

I would like to apply for the following level of tuition assistance:Level 1 Assistance $ 25 deduction for 8-week session Session fee will be $175Level 2 Assistance $ 50 deduction for 8-week session Session fee will be $150Level 3 Assistance $ 100 deduction for 8-week session Session fee will be $100Full Tuition Assistance:ALLof the criteria below required $ 5 Registration fee applies

CRITERIA FOR DEMONSTRATING NEED: please attach official documentation needed to demonstrate:Qualification to receive free school lunchesQualification for MedicaidMost Recent Income Tax Return & W-2s REQUIRED

$ _____Total Annual Household IncomePlease list any unusual circumstances (debts, illnesses, etc.) that contribute to your need for assistance:

Volunteers play a significant role in the success of programs offered at Heroes on Horseback. Your involvement is encouraged.Please check how you will be willing to volunteer:

work on fundraisers serve as volunteer class coordinator help with barn chores help with lessons

Participant Name: Home Phone: Cell Phone:

Address: City/State/Zip: E-Mail:

Marital Status: Married Single Divorced/Seperated Widowed

Number ofChildren/Ages:

Number of people inhousehold:

I understand that when Tuition Assistance is available it is granted for one (1) Session with theopportunity for renewal if the need continues.APPLICANT SIGNATURE:DATE:

For office use only:Denied (D) or Granted (G): Level Granted: HOH Officer Initials / Date:

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