Miracles in Motion - Student Application (March 2018) 

Thank you for your interest in the classes that Miracles In Motion provides. Please complete this application form to sign up for our classes.  In addition, please visit our website (www.miraclescanmoveyou.com) to download and print the Medical Form. This document must be completed and signed by the participant's referring medical professional.  

This application form may take 15-30 minutes because of the detailed information about the participant. We look forward to having the participant out at the farm and want to learn as much information as possible.

PARTICIPANT'S APPLICATION










ex: 5ft. 6in.

ex. 120 lbs.






PrimaryParent/Legal Guardian/Caregiver Information:
If participant is completing this form, over 18 years old, and responsible for themselves; please skip this section. 









Include only if you routinely check it
School, Group Home or Organization Affiliation (if applicable)





1 of 8


This section will help us place the participant in classes and sessions that best works with the participants schedule and needs, along with our class schedule and instructor availability. This is no guarantee that the participant will be placed in all the sessions/classes/times selected below but will give our staff a better understanding of the participant’s interest and availability to hopefully place them in desired and fitting classes. If you know the participant is participating in our Hippotherapy program please feel free to skip this page and submit application.

RETURNING STUDENTS (If you are a new student please skip this section).


ABOUT THE PARTICIPANT
Have you ever had that feeling where you wished people knew more about who your child really is? 



COMMUNICATION




ABOUT THE PARTICIPANT (cont'd)
PHYSICAL



SELF-REGULATION



SENSORY



Participant Health History


ex: 1/1/2015


ex: 1/1/2015

Please indicate current or past special needs in the following areas. If you mark yes please explain below the question what the need is and how it may effect the participant in class.






































CLASS AND PROGRAM POLICY INFORMATION
Weather Related Cancellation Policy
If inclement weather develops or if it is necessary to cancel classes for any reason, Miracles In Motion PATH Certified Instructors will call the individual riders and volunteers scheduled. In warm weather classes will be cancelled if the heat index rises above 90 degrees. In cold weather, classes will be closed if wind chill is 30 degrees or colder and/or snow or ice conditions require it. When we severe weather happens classes are immediately cancelled when a weather warning is issued in either Johnson or Linn County.
Summary of Fees
Horse101 
  Duration - 4 weeks
  Weekly Class - 50 minutes Saturday Mornings Only
  Fee - $120

Therapeutic Riding 
  Duration - 5 weeks
  Weekly Class - 50 minutes Monday thru Thursday Evenings
   Fee - $250

PARTICIPANT CLASS INFORMATION






PHOTO RELEASE: CONSENT OR NON-CONSENT

Please sign ONE of the following two consent agreements:

Photo Release Consent

I DO consent to and authorize the use and reproduction by Miracles in Motion, its advertising agencies, news, radio, and any other persons, of any and all photographs and any other audiovisual materials taken of me/ my son/ my daughter/ my ward for promotional printed material, educational activities, exhibitions, newspapers, television, brochures, pamphlets or for any other use for the benefit of the program.



Photo Release Non-Consent (please only sign consent or non-consent)

DO NOT consent to or authorize the use and reproduction by Miracles in Motion, its advertising agencies, news, radio, and any other persons, of any and all photographs and any other audiovisual materials taken of me/ my son/ my daughter/ my ward for promotional printed material, educational activities, exhibitions, newspapers, television, brochures, pamphlets or for any other use for the benefit of the program.



EMERGENCY MEDICAL TREATMENT 

EMERGENCY CONTACT




SIGN ONE OF THE FOLLOWING TWO CONSENT PLANS
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT


In the event emergency medical aid/treatment is required due to illness or injury during the process of providing volunteer services, or while being on the property located at 2049-120th St., Swisher, IA, I GIVE MY CONSENT to authorize Miracles in Motion to secure and obtain medical treatment and transportation if needed. I agree to the release of my records upon request to the authroized individual or agency involved in providing the medical emergency treatment.



Non-Consent Plan (only sign consent or non-consent)

DO NOT GIVE MY CONSENT for emergency medical aid/treatment in the case of illness or injury during the process of receiving services or while being on the property located at 2049 – 120th Street, Swisher, Iowa. In the event emergency treatment/aid is required, I wish the following procedures to take place, or the following persons to be contacted:




CONFIDENTIALITY POLICY & AGREEMENT 

It is the policy of Miracles in Motion to preserve the right of confidentiality for all individuals in the program. This policy applies to all volunteers, staff, board members, participants and anyone who might obtain confidential or sensitive information.

 

Access to student forms on file is restricted to staff, instructors, and therapists. Pertinent information will be given to volunteers working in the class on a need to know basis by the instructor, program specialist or therapist without reference to diagnosis. After each class or session, the instructor or therapist will ask the Horse Leader and Sidewalkers (volunteers) to discuss each student’s ride. With this feedback, the instructor or therapist is able to make any changes necessary to make their ride the best possible experience, providing optimal therapeutic benefits to that student. All volunteers, staff, board members, and participants shall keep confidential all medical, social, personal and financial information, as well as student evaluations, individual goals and progress, and referrals regarding a person and his/her family.

 

Miracles in Motion may disclose medical and/or sensitive information to agents and outside health care providers involved in therapy only with the specific written consent from the rider. Informed consent for disclosure may be given only by competent adults, parent(s), legal representatives and others defined by state statue. In case of emergency, student forms will be made available as needed to appropriate personnel.

 

Personal and professional penalties that can result from breaching confidentiality will include reprimand, with the potential loss of job responsibilities, and may ultimately lead to termination from this organization.

 

I understand and agree to observe the confidentiality policy of Miracles in Motion Therapeutic Equestrian Center.





LIABILITY RELEASE & INDEMNITY AGREEMENT

 **CAUTION: THIS IS A RELEASE PLEASE READ CAREFULLY**

I have chosen to be on the property where Miracles in Motion holds equestrian classes & activities, and will be in proximity of, and possibly work with and/or ride the horses, may receive riding instruction and/or assist with property maintenance. I assume full responsibility for any and all bodily injuries or damages sustained where classes/activities are held, when riding horses and/or when maintaining the property. I understand that Miracles in Motion requires me to wear properly fitted and secured ASTM-standard/SEI certified protective headgear at all times when riding horses.

 

I, for my heirs, administrators, personal representatives or assigns, release and discharge Miracles in Motion Therapeutic Equestrian Center and its employees, agents, board of directors, volunteers, instructors and others acting on behalf of all claims resulting from or arising out of my bodily injury or damage that may be sustained which may occur as a result of being on the Miracles in Motion property.

I understand that anyone riding or near a horse can suffer bodily injuries, as a number of inherent risks are associated with a domesticated animal activity. A domesticated animal, horse, may behave in a manner that results in damages to property or an injury or death to a person. Risks associated with the activity may include injuries caused by bucking, biting, stumbling, rearing, trampling, scratching, pecking, falling, or butting. The domesticated animal may react unpredictably to conditions, including, but not limited to, a sudden movement, loud noise, an unfamiliar environment, or the introduction of unfamiliar persons, animals, or objects. The domesticated animal may also react in a dangerous manner when a condition or treatment is considered hazardous to the welfare of the animal; a collision occurs with an object or animal; or a participant fails to exercise reasonable care, take adequate precautions, or use adequate control when engaging in a domesticated animal activity, including failing to maintain reasonable control of the animal or failing to act in a manner consistent with the person’s abilities.

 

It is mutually understood and agreed that the provision of this liability release shall constitute a waiver of liability for injury to, or death of an equine activity participant, including, but not limited to those provided for under the following provisions of the Iowa Code Chapter 673:

WARNING

Under Iowa law, a domesticated animal professional is not liable for damages suffered by, an injury to, or the death of a participant resulting from the inherent risks of domesticated animal activities pursuant to Iowa Code Chapter 673. You are assuming inherent risks of participating in this domesticated animal activity.

 

I represent that I am 18 years of age or older, and of sound mind. I have read and agree to all of the terms of this entire liability release and indemnity agreement.




All parts of this agreement shall apply to me, and the children/legal wards listed above. This agreement is binding when I enter the property where Miracles in Motion holds classes/activities for any purpose, when I am near horses on the premises, and/or if I receive riding instruction.