Annual Update Form

Participant's Name*

First Last

Home Phone*

Cell Phone*

Date of Birth*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Gender Identification (optional)*

Male
Female
Prefer not to answer

Age*

Height*

Height and weight are used in horse and volunteer assignments.

Weight*

Ethnicity*

White
Hispanic, Latino, Spanish
Black or African American
Asian
American Indian or Alaskan Native
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
Other race or ethnicity
Prefer not to answer

Disability / Diagnosis / Pertinent Information*

School or Institution Presently Attending*

Teachers Name

First Last

Primary Contact's Name*

First Last

Relation

Phone (Day)*

Phone (Cell)*

Email*

Please indicate the program(s) you are interested in:*

Riding
Carriage Driving
Equine Learning

Does participant see any of the following professionals:*

Physical Therapist
Occupational Therapist
Mental Health Professional
Speech Language Pathologist
None
Other

Movement / Coordination*

Posture*

General Attitude & Behavior*

Perceptual & Balance Problems*

Communication Challenges & Methods (verbal, sign, PEC)*

Cognitive Abilities (age level, multi step directions)*

What are your goals for the riding sessions (i.e. riding skills, behavioral changes, physical improvements, paying attention) Please be specific.*

Any special considerations? (i.e. health, precautions, medications, etc.)

Describe any previous horseback riding experience

Areas of interest, games, and activities enjoyed*

Suggestions / Comments

Authorization for Emergency Medical Treatment

Physician's Name*

First Last

Preferred Medical Facility*

Health Insurance Company*

Policy Number

Health Concerns

In the event that 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 HIGH HOPES THERAPEUTIC RIDING, INC. to:*

Release client records upon request to the authorized individual or agency involved in the medical emergency treatment

In the event that 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 HIGH HOPES THERAPEUTIC RIDING, INC. to:*

Secure and retain medical treatment and transportation, if needed.

Consent Plan

I give consent for emergency medical treatment/aid (including x-ray, surgery, hospitalization, medication, and any treatment procedure deemed “life saving” by the physician) in the event of illness or injury while on the property of the agency.*

(to be invoked in the event that your Emergency Contact cannot be reached.)

If you choose non-consent for emergency medical treatment/aid in the event of illness or injury while on the property of the agency, please request a Non-Consent Form, which requires notarization.

Date*

Signature (Type name to sign)*

Photo Release*

I hereby consent to and authorize
I do not consent to nor do I authorize

High Hopes Therapeutic Riding, Inc. 1) to use my child’s photograph or image in its print, online and video publications; 2) release High Hopes Therapeutic Riding, Inc., its employees and any outside third parties from all liabilities or claims that I might assert in connection with the above-described activities and 3) waive any right to inspect, approve or receive compensation for any materials or communications, including photographs, videotapes, DVDs, website images or written materials, incorporating photos/images of me(my child).

Date*

Signature (Type Name to Sign)*

Confidentiality Policy*

I hereby consent to and authorize
I do not consent to nor do I authorize

At High Hopes we place great importance on protecting the confidential information of our clients, our volunteers, and our staff. "Confidential Information" includes, but is not limited to, personally identifiable information such as surnames, clients, and information about their disabilities or special needs must be protected as confidential information. I shall never disclose confidential information to anyone other than High Hopes staff. I must seek staff permission before taking any pictures or videos. I have read and understand the High Hopes Confidentiality Policy and agree to abide by the same.

Date*

Signature (Type Name to Sign)*

Liability Release (Required)*

(Name) would like to participate in the High Hopes Therapeutic Riding Inc. program. I acknowledge the risks and potential for risks of horseback riding and related equine activities, including grievous bodily harm. However, I feel that the possible benefits to myself/my child/my ward are greater than the risk assumed. I hereby, intending to be legally bound for myself, my heirs and assigns, executors, and administrators, waive and release forever all claims for damages against High Hopes Therapeutic Riding, Inc., its Board of Directors, Instructors, Therapists, Aides, Volunteers, and/or Employees for any and all injuries and/or losses I/my child/my ward may sustain while participating in the Program from whatever cause including but not limited to the negligence of these released parties. The undersigned acknowledges that he/she has read this Registration and Release Form in its entirety; that he/she understands the terms of this release and has signed this release voluntarily and with full knowledge of the effects thereof.

Date*

Signature (Type Name to Sign)*

Phone

Program - Participant Registration & Annual Update Form

Authorization for Emergency Medical Treatment

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