Heartland Therapeutic Riding - Participant Application
Participant's Name (First Last)
Participant's cell phone
Participant's home phone
Youth small (6-8)
Youth medium (10-12)
Youth large (14-16)
Program Participation - which program are you interested in? (If child is under 6, they are not eligible for Therapeutic Riding)
Is participant a current Heartland rider?
Status - if you are a current Heartland participant completing your annual update, please select "Active". If you are a new rider please select "Potential Therapeutic Riding".
Potential Therapeutic Riding
Please check here if you plan to participate in the upcoming session.
Yes, I plan to participate in the next session.
Are there any days/times participant is
able to ride?
Please list names and ages of siblings
How did you hear about Heartland?
Who were you referred by?
Emergency Contact Person
Other Family relative
Emergency Contact Preferred Phone
Emergency Contact Alternate Phone
- In the event emergency medical aid/treatment is required due to illness or injury while participating or being on the property of Heartland Therapeutic Riding, Inc., I authorize Heartland Therapeutic Riding to secure and retain medical treatment and transportation, if needed.
Edit this text
Yes, I consent to the above emergency medical treatment
No, I DO NOT consent to the above emergency medical treatment
If you do not consent to the above procedures please indicate what procedures you would like us to follow in the event of an emergency:
Diagnosis and Medical History
Attention Deficit Disorder
Auditory Processing Disorder
Fetal Alcohol Syndrome
Spinal Cord Injuries
Traumatic Brain Injury
Attention Deficit Disorder
Auditory Processing Disorder
Fetal Alcohol Syndrome
Spinal Cord Injuries
Traumatic Brain Injury
Time of onset or diagnosis
Please tell us anything else you feel would be beneficial for us to know about the above diagnosis:
Class category:(child = 12 and under, youth = 13 - 17, adult = over 18)
child - physical limitations only
youth - physical limitations only
adult - physical limitations only
child - cognitive limitations only
youth - cognitive limitations only
adult - cognitive limitations only
child - physical & cognitive limitations
youth - physical &cognitive limitations
adult - physical & cognitive limitations
walks without assistance
walks with assistance
does not walk
Please list any assistive devices required for walking.
Please list any additional adaptive equipment required.
Please list any implanted or indwelling devices such as shunts, catheters, hearing aids, G-tubes,etc.
Include location of implant or device
Please list any recent surgeries and date of surgery, if applicable
Times of Dosages
Are there any notable side effects of medications that we should be aware of?
Allergies/Special Medical Considerations
Date of most recent tetanus shot
Are there any specific dietary restrictions?
Does participant have any issues with skin integrity? Bruises easily, chaffing, sores, skin breakdown?
Describe participant's fine motor skills:
Describe participants gross motor skills:
Does participant have any range of motion limitations? If so, please describe.
Please describe participant's general muscle tone. For example, low tone, high tone, low in core, high in lower extremities,etc.
Is participant receiving Physical Therapy? If so, where, how frequently and goals?
Is particpant receiving Occupational Therapy? If so, where, how frequently and goals?
Is participant receiving Speech Therapy? If so, where, how frequently and goals?
Does participant have any vision impairments? If so, please describe.
Does participant have any hearing impairments? If so, please describe.
Does participant have any history of seizures?
Type of seizures
Average number of seizures per month
Warning signs and/or seizure triggers
Are seizures controlled
How long since last seizure?
Please describe any pertinent medical or health information not included above.
By typing your name in the box below you indicate that the above information is correct to the best of your knowledge. You also understand that participation in any Heartland Therapeutic Riding program also requires completion of our Medical Statement form which must be signed by a physician indicating medical approval of participation. (Parent or Guardian signature required if participant is under 18)
Why are you interested in Hippotherapy/Therapeutic Riding? What are some goals participant has pertaining to riding? Strengthen core, improve balance, increase concentration, learn riding skills, etc.
What are participant's life goals? Drive a car, ride a bike, live independently, make friends, etc. These are not necessarily riding goals, but life goals.
Does participant have any previous experience with horses? If so, please describe.
Does participant do any other activities?
Effective behavioral/emotional techniques used
Does participant have any issues with tactile defensiveness? If so , please describe.
Describe participant's fears
Describe participant's motivators
Does participant have any extreme sensitivities? If so, please describe.
What music does participant like?
Good social skills, interacts well with others in most social situations
Varied social skills, sometimes awkward or inappropriate in social situations
Poor social skills, difficulty interacting with others or inappropriate in social situations
Sometimes cooperative, but can be challenging in some situations
Knows left and right
At or above age level
below age level
does not read
Knows all basic shapes
Knows some basic shapes
Knows very few basic shapes
Does not know shapes
does not count
Knows all basic colors
Knows some basic colors
Knows very few basic colors
Does not know colors
Expressive Communication Skills
Limited verbal (single words, echo)
How does participant express anger?
How does participant express happiness?
How does participant express sickness?
How does participant express pain?
How does participant express fear?
Please describe participant's receptive communication skills. (
For example, understands one step directions, understands appropriate for age, limited understanding of what is spoken,etc.)
Is there anything else you would like us to know about how participant communicates?
You will also be required to sign a hard copy of this form in order to participate in any capacity at Heartland Therapeutic Riding, Inc
Participant, or Participant’s parents or legal guardians if Participant is a minor,
Acknowledge the risks and potential for risks in involvement and participating in equine activities. I understand that despite all precautions taken by HTR, equine activities are by their nature “high risk” activities, and horses as natural prey animals may instinctively resort to unpredictable equine behavior despite all care taken by HTR. I confirm that with this knowledge, I believe the possible benefits to myself/my child/my ward are greater than the risks assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever, and will bring no litigation, suit or
claims of any kind for damage or otherwise, including but not limited to personal injury or property damage,
against Heartland Therapeutic Riding, Inc., its Board of Directors, Officers, Instructors, Therapists, Aides, Volunteers and/or Employees (hereinafter collectively “the Released Parties”),
for any and all injuries and/or losses I/my child/my ward may sustain while participating in any function sponsored by, or held at Heartland Therapeutic Riding, Inc.’s premises, and/or HTR sponsored activities held off premises, even for claims arising from the alleged negligent acts or omissions of the Released Parties.
I Acknowledge and confirm that I have read and accept the following statutory warning from the State of Kansas and assumption of risk terms related to participation in domestic animal activities and agree to be bound by same:
KANSAS DOMESTIC ANIMAL LIABILITY ACT WARNING
“Under Kansas law, there is no liability for an injury to or the death of a participant in domestic animal activities resulting from the inherent risks of domestic animal activities, pursuant to sections 1 through 4. You are assuming the risk of participating in this domestic animal activity.
Inherent risks of domestic animal activities include, but shall not be limited to:
The propensity of a domesticated animal to behave in ways, i.e. running, bucking, biting, kicking, shying, stumbling, rearing, falling or stepping on, that may result in an injury, harm or death to persons on or around them;
the unpredictability of a domestic animal’s reaction to such things as sounds, sudden movement and unfamiliar objects, persons, or other animals;
certain hazards such as surface and subsurface conditions;
collisions with other domestic animals or objects; and
the potential of a participant to act in a negligent manner that may contribute to injury to the participant or others, such as failing to maintain control over the domestic animal or not acting within such participant’s ability.”
K.S.A. §60-4002 et. seq. (1994)
I acknowledge Participant wishes to participate in an equestrian program at HTR and assumes the risks for such participation. If the participant is my child or ward, I have discussed their participation with their doctor. I understand and agree that pursuant to paragraph 3 (a) and (b) above, the Released Parties have NO LIABILITY in the event of any accident or loss of Participant that may occur.
Participant also acknowledges that no person will be accepted for participation in a Heartland Therapeutic Riding, Inc. program and/or activity at the Heartland Therapeutic Riding, Inc. facility until this form has been completed by the Participant and/or Participant’s parent(s)/guardian. If the person is of legal age (18), he or she may complete for form if he or she is legally competent to do so. All activities will be under supervision and, although reasonable effort will be made to avoid any accident, the Released Parties have NO LIABILITY.
Participant, or Participant’s parents or legal guardians (if a minor), may from time to time bring guests to the facility. All guests to this facility, including Participant’s parents or legal guardians, must sign the facility’s separate Liability Waiver and Release form as found on HTR’s daily sign-in page. Participant or Participant’s legal guardians accept responsibility for signing this form, and/or having all guests they bring to the facility sign this form. Should they fail to do so, Participant and/or Participant’s legal guardians agree to fully indemnify and hold harmless HTR and the Released Parties from all damages, including reasonable attorneys fees and costs, expended in defending against any claims asserted by guests to the facility.
By typing your name in the box below you accept the Release of Liability terms and conditions as indicated. (Parent/Guardian signature required if participant is under 18)
Photo, Media & Observation Release:
I, Participant, or Participant’s parents or legal guardians if Participant is a minor,
Consent and authorize HTR to observe Participant’s therapy session which may and can include taking photographs or motion pictures of Participant; and to produce videotapes, audiotapes, closed circuit television programs, web casts,
the foregoing types of media are called the “Materials” in this Consent and Release form).
Acknowledge that the observation of Participant’s therapy sessions may include observation by guests of HTR who are taking a tour of the facility or engaging in other HTR authorized activities. Guests may include prospective volunteers, clients, donors, staff, and others interested in HTR.
Authorize HTR to copyright the Materials, and authorize HTR to use, reuse, copy, publish, display, exhibit, reproduce, license to third parties, and distribute the Materials in any educational or promotional materials or other forms of media, which may include, but are not limited to therapeutic publications, catalogs, articles, magazines, recruiting brochures, websites, social media or publications, electronic or otherwise, without notifying me; and agree that HTR may identify Participant by name and such other identifying information as age, graduation date, hometown, etc.
Participant agrees that Participant is participating on a voluntary basis and will not receive any payment from HTR for signing this release or as a result of any use or publication of the Materials.
By typing your name in the box below, you acknowledge that you have read Heartland's Photo Release and indicated your preference.
(Parent/Guardian signature required if participant is under 18)
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