Participant Program Registration Form

Full Name *
Your answer
Address *
Your answer
Home Phone
Your answer
Cell Phone
Your answer
E-mail *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Weight *
Your answer
Height *
Your answer
If participant is a minor, parent/guardian name and address, if different from above
Your answer
Registration For: *
Would you like to stay in touch by e-mail to hear about other SPIRIT activities and programs? (you can always select 'no' later) *
For EAP and TR Program participants -Please list diagnoses or condition(s) indicated for Equine Assisted Therapies (consult your physician as needed) *
Your answer
For Equine Assisted Psychotherapy Program participants - Please, let us know your therapeutic goals (consult your Mental Health provider as needed)
Your answer
For Therapeutic Riding Program participants - Please, let us know your therapeutic goals (consult your Physician as needed)
Your answer
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 Spirit OEP 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 - I do 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. This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed "lifesaving" by the physician. This provision will only be invoked if the emergency contact is unable to be reached. *
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.
In the event of an emergency, contact *
Your answer
Relationship *
Your answer
Phone Number *
Your answer
I hereby grant Spirit Open Equestrian Program permission to interview me/my child and/or to use my likeness in photographs/videos in any and all of its publications and in any and all other media, whether now known or hereafter existing. I will make no monetary or other claim against Spirit OEP or its staff for the use of the interview and or the photographs/videos. This is a total release in perpetuity to any right, title or interest. *
CONSENT TO USE ELECTRONIC MAIL Your privacy is important to us. As a general rule, this office will never send sensitive information (i.e. your medical history). However, please be advised that we and our providers use standard (not encrypted) electronic mail to share information regarding your treatment (i.e. consultation notes, progress reports)with our counselors and therapists and they may need to share it with other healthcare providers and/or organizations involved in your care, such as your referring agency, your insurance company and /or to you upon your request.Please be aware that it is possible, although unlikely, that a third party could intercept or view this information. *
Date *
MM
/
DD
/
YYYY
Participant's or Parent's (if participant is a minor) electronic signature, as proof that all above is accurate. By typing your name here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request to sign a paper copy instead. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. If you need to change any information in this document, please contact spiritoep@spiritequestrian.org *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service