HTR Participant Application 2023
Today's Date
General Info
Participant's Name (First Last)
Gender
Please select...
Male
Female
Other
Participant's birthdate
Participant's Address
City
State
Please select...
KS
MO
Zip Code
Is Participant their own Guardian?
Yes
No
Parent/Guardian/Primary HTR Contact names:
Participant's cell phone (for last-minute updates and/or cancellations):
Participant's home phone
Most of our communication about classes, scheduling and cancellations is done via email. Please give an email that is checked regularly!
Participant's Email
T-shirt size
Please select...
Youth small (6-8)
Youth medium (10-12)
Youth large (14-16)
Adult small
Adult medium
Adult large
Adult XL
Adult XXL
Program Participation - which program are you interested in? (If child is under 4, they are only eligible for Occupational Therapy Utilizing Hippotherapy)
Please select...
Therapeutic Riding
Occupational Therapy Utilizing Hippotherapy
Summer Horsemanship Camp
If you are applying for our Summer Horsemanship Camps, please select which week of camp you want:
**Camp registrations will not be accepted until January 15th
**
Please select...
Cowpokes -Regular HTR Riders only- June 10-14
Wranglers -5th-8th Grade- June 24-28
Lil' Buckaroos -1st & 2nd Grade- 1/2 DAY!- July 8-12
Jr Wranglers -3rd-5th Grade- July 22-26
Emergency Information
Emergency Contact Person
Relationship
Please select...
Parent
Guardian
Spouse
Friend
Grandparent
Aunt/Uncle
Other Family relative
Other
Emergency Contact Preferred Phone
Diagnosis and Medical History
Primary Diagnosis
Please select...
Angelmans Syndrome
Attention Deficit Disorder
Auditory Processing Disorder
Autism
Brain Injuries
Cardiovascular
Cerebral Palsy
Congenital Anomaly
Deafness
Developmental Delay
Down Syndrome
Encephalopathy
Epilepsy
Fetal Alcohol Syndrome
Hearing Impairment
Hydrocephalus
Hypotonia
Learning Disabilities
Mitochondrial Disease
Multiple Sclerosis
Muscular Dystrophy
OCD
Other
Rhetts Syndrome
Seizure Disorder
Smith-Lemli-Opitz syndrome
Spina Bifida
Spinal Cord Injuries
Stroke
TBI
Traumatic Brain Injury
Visual Impairment
None-Typically developing
Secondary Diagnosis
Please select...
Angelmans Syndrome
Attention Deficit Disorder
Auditory Processing Disorder
Autism
Brain Injuries
Cardiovascular
Cerebral Palsy
Congenital Anomaly
Deafness
Developmental Delay
Down Syndrome
Encephalopathy
Epilepsy
Fetal Alcohol Syndrome
Hearing Impairment
Hydrocephalus
Hypotonia
Learning Disabilities
Mitochondrial Disease
Multiple Sclerosis
Muscular Dystrophy
OCD
Other
Rhetts Syndrome
Seizure Disorder
Smith-Lemli-Opitz syndrome
Spina Bifida
Spinal Cord Injuries
Stroke
TBI
Traumatic Brain Injury
Visual Impairment
Please tell us anything else you feel would be beneficial for us to know about the above diagnosis:
Height
Weight
Cognitive Impairment
Please select...
None
Mild
Moderate
Severe
Physical Impairments
Please select...
None
Mild
Moderate
Severe
Ambulatory Status
Please select...
walks without assistance
walks with assistance
does not walk
Please list any implanted or indwelling devices such as shunts, catheters, hearing aids, G-tubes,etc.
Include location of implant or device
:
Does participant have any history of seizures?
Please select...
Yes
No
Seizure Information
Type of seizures
Average number of seizures per month
Warning signs and/or seizure triggers
Are seizures controlled
Please select...
Yes
No
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)
Please check this box
Potential
Contact Information