1301 Convent Road NE, Cullman, AL 35055, Phone: 256-841-6290 Email: Hope@hopehorses.org
Participant Application To be completed by the adult participant, participant’s parent, or participant’s legal representative.
Participant’s Name: ______________________________ Birth date: ______________ Height: _________ Weight: _________ Gender: M F Address: ______________________________________________________________ Home Phone: __________ Other Phone: ____________ E-mail: _________________
Parent/Caregiver Name(s) and Phone Number(s), if under age 18 or dependent adult:
_____________________________________________________________________ Emergency Contact (Name and Phone number): _______________________________ ______________________________________________________________________ Employer/School (Name and Phone number): _________________________________
HEALTH HISTORY Diagnosis: ____________________________________ Date of Onset: ____________ Please check whether any of the following conditions apply: o Atlantoaxial Instability o Chiari II Malformation o PVD o Coxa Arthrosis o Tethered Cord o Respiratory Compromise o Heterotopic Ossification o Hydromyelia o Recent Surgeries o Myositis Ossificans o Allergies o Substance Abuse o Hip Subluxation/Dislocation o Animal Abuse o Thought Control Disorders o Osteoporosis o Cardiac Condition o Weight Control Disorder o Neuromuscular Disorder/ MS o Abuse o Under 4 Years Old o Spinal Fusion/Fixation o Blood Pressure Control o Indwelling Catheters o Spinal Joint Instability o Dangerous to Self o Photosensitivity o Spinal Curvature/Scoliosis o Dangerous to Others o Medication Precautions o Hydrocephalus o Fire Settings o Poor Endurance o Shunt o Hemophilia o Skin Breakdown o Seizure o Medical Instability o Joint Replacement o Spina Bifida o Migraines o Pathologic Fractures
Comments: _________________________________________________________________ Allergies: ____________________________________________________________________
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Medications (List all medications you are currently taking. Include prescription and OTC medications.) ____________________________________________________________________________ ____________________________________________________________________________
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
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 Hope Horses, Inc. 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.
__________________________________________________ _______________________ Parent/Guardian/Participant Signature Date
Hope Horses, Inc. often takes still pictures and/or videos of students, clients, volunteers and instructors. This is done for several reasons. Rider progress and acquisition of skills provide instructors and clients with necessary information and positive feedback. Photos/videos are also used in brochures, presentations, posters, and on our website for publicity. They are also occasionally provided to students for keepsakes.
Please check one of the boxes below to indicate your preference for photograph/video of you/your child for the aforementioned purposes.
□ Do Not Consent Consent: I, (name) _____________________________ , give consent to Hope to take still and/or video photographs of myself, or the individual for which I am legally responsible. ___________________________________________________ ________________________ Participant/Parent/Guardian/Caregiver Signature Date ___________________________________________________ ________________________ Instructor or Representative of Hope Signature Date
The patient listed below is interested in participating in supervised therapeutic horseback riding
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activities with the Hope Horses, Inc. In order to provide this service, our center requests that you complete the following medical history and release for riding.
Participant: _________________________ DOB: _________ Height: _______ Weight: ______ Diagnosis:__________________________ Date of Onset: ________________ Past Surgeries: _______________________________________________________________ Prospective Surgeries: _________________________________________________________ Medications: _________________________________________________________________
Please indicate any special precautions/needs: ______________________________________
For Participants with Down Syndrome
Prior to starting mounted activities, a medical examination with special reference to neurologic function must not reveal atlantoaxial instability or focal neurologic disorder. Additionally, initial lateral or side view X-rays, within the past 5 years, of the upper cervical region in full flexion and full extension are required to determine the atlanto-dens interval and rule out AAI.
___ Negative Cervical X-ray for Atlantoaxial Instability Date of X-ray: _______________ ___ Negative for clinical symptoms of Atlantoaxial Instability Date of Examination: _________
Precautions and Contraindications
Please note that the following conditions may suggest precautions and contraindications to therapeutic horseback riding. Please note whether these conditions are present and to what degree.
o Atlantoaxial Instability Y N o Coxa Arthrosis Y N o Cranial Deficits Y N o Heterotopic Ossification/Myositis Ossificans Y N o Joint subluxation/dislocation Y N o Osteoporosis Y N o Pathologic Fractures Y N o Spinal Joint Fusion/Fixation Y N o Spinal Joint Instability/Abnormalities Y N Comments: __________________________________________________________________
o Hydrocephalus/Shunt Y N Date of Last Revision: ___________ o Sensory Deficit Y N
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o Seizure Y N Date of Last Seizure: ____________ o Spina Bifida/Chiari II malformation Y N o Tethered Cord/Hydromyelia Y N Comments: __________________________________________________________________
o Cardiac Condit ion Y N o Physical/Sexual/Emotional Abuse Y N o Blood Pressure Control Y N o Exacerbations of medical conditions (i.e. RA, MS) Y N o Hemophilia Y N o Medical Instability Y N o Migraines Y N o PVD Y N o Respiratory Compromise Y N o Substance Abuse Y N o Thought Control Disorders Y N o Weight Control Disorder Y N Comments: __________________________________________________________________
Allergies: ____________________________________________________________________________ ____________________________________________________________________________
Medications: ____________________________________________________________________________ ____________________________________________________________________________
To my knowledge, there is no reason why this person cannot participate in supervised equine activities. However, I understand that the PATH center will weigh the medical information above against the existing precautions and contraindications. I concur with a 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: __________________________________________________________________ Signature: _____________________________________________ Date: _________________ Address: ____________________________________________________________________ Phone: (_____)____________________________ License/UPIN Number: ________________ Release of Liability To be completed by the participant or participant’s parent, or participant’s legal representative if under the age of 18.
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This release of liability is made and entered into on this date_________ , by and between Hope Horses, Inc. hereinafter known as HOPE, and staff/participant/volunteer (print name) ______________________, hereinafter known as participant, and (if a minor or incompetent adult) participant’s parent, legal guardian, or legal representative (print name) ____________________________. In return for participation in HOPEs therapeutic horseback riding activities, special events and fundraisers, the participant, his/her heirs, assigns, and legal representatives hereby expressly agree to the following:
1. Participant agrees to assume any and all risks involved in or arising from participant’s
participation or presence upon the property and facilities, including, without limitation, but not limited to the risks of death, bodily injury, property damage, falls, kicks, bites, collisions with vehicles, horses, or stationary objects, fire or explosion, the unavailability of emergency medical care, or the negligence or deliberate act of another person.
2. Participant agrees to hold Hope and all of its successors, assigns, subsidiaries, franchisee,
affiliates, officers, directors, employees, agents, and boarders completely harmless and not liable and release them from all liability whatsoever and agrees not to sue them on account of or in connection with any claims, causes of action, injuries, damages, costs or expenses arising out of participant’s participation and/or presence upon HOPE’s property and facilities, including without limitation, those based on death, bodily injury, property damage, including consequential damages, except if the damages are caused by the direct willful and wanton negligence of HOPE.
3. Participant agrees to waive the protection afforded by any statue or law in any jurisdiction whose
purpose, substance and/or effect is to provide that a general release shall not extend to claims, material, or otherwise, which the person giving the release does not know or suspect to exist at the time of executing the release.
4. Participant agrees to indemnify and defend Hope against, and hold it harmless from, any and all claims, causes of action, damages, judgments, costs, or expenses, including attorney’s fees, which in any way arise from participant’s participation and/or presence upon HOPE’s property or facilities.
5. This contract is non-assignable and non-transferable and is made and entered into the State of
Alabama and shall be enforced and interpreted under the laws of this state. Should there be any clause in conflict with State Law, then that clause is null and void. When Hope and participant or participant’s parent, legal guardian, or adult caregiver signs this contract, it will then be binding on both parties, subject to the above terms and conditions.
WARNING: Under Alabama law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities, pursuant to the Equine Activities Liability Protection Act.
Participant (Parent/ Legal Guardian/Legal Representative if under 18 years of age)
Signature ________________________________________________ Date _______________________
Signature________________________________________________ Date _______________________
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Hope Office Use Only
Signatures required: (√ when verified)
Handbook Acknowledgement ____ Authorization for Emergency Medical Treatment ____ Photography Consent ____ Physician’s Statement ____ Release of Liability ____ Hope Representative Signature ____
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