HTR Participant Application 2023

Today's Date

General Info

Participant's Name (First Last)

Gender

Participant's birthdate

Participant's Address

City

State

Zip Code

Is Participant their own Guardian?

YesNo

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

Program Participation - which program are you interested in? (If child is under 4, they are only eligible for Occupational Therapy Utilizing Hippotherapy)

If you are applying for our Summer Horsemanship Camps, please select which week of camp you want: **All camps are FULL for 2023**

Emergency Information

Emergency Contact Person

Relationship

Emergency Contact Preferred Phone

Diagnosis and Medical History

Primary Diagnosis

Secondary Diagnosis

Please tell us anything else you feel would be beneficial for us to know about the above diagnosis:

Height

Weight

Cognitive Impairment

Physical Impairments

Ambulatory Status

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?

Seizure Information

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)

Please check this box

Potential

Contact Information