ROCK Participant Camp Application

After clicking submit, be sure to scroll back down and sign electronically. An email should be sent after you sign.

Camp Overview

Camp Overview

Camps Types:

Camp Courage: (June 19th-June 22nd Family day on June 23rd) This Summer Camp is designed for children ages 8-14 years old of all military branches of Active Duty Service Members and Veterans. This horsemanship class includes ground and riding instruction, classroom activities, and equine-facilitated learning through various activities. The camp will focus on building character traits, including honor, integrity, respect, responsibility, courage, and perseverance.Camp Bright Side session 1:$300 (June 5th-June 8th) Ages 8-15. Camp Bright Side is ROCK's inclusion camp for riders of different abilities to make connections and learn from each other to build a stronger sense of community. The curriculum will include riding skills, horse care instruction, and classroom activities. Camper must have independence on the ground, be able to follow directions, and toilet by themselves. All applications will be reviewed by staff for suitability for the program.

Camp Bright Side session 2: $300 (June 12th- June 15th) Ages 8-15. Camp Bright Side is ROCK's inclusion camp for riders of different abilities to make connections and learn from each other to build a stronger sense of community. The curriculum will include riding skills, horse care instruction, and classroom activities. Camper must have independence on the ground, be able to follow directions, and toilet by themselves. All applications will be reviewed by staff for suitability for the program.

Is the participant's parent or guardian currently serving or has previously served in the United States Military?

Branch

Status:

Rank

Page 3

Participant information

What is the participant looking to gain by riding at ROCK? (ie. horse knowledge, more independence)

What was the participants previous riding experience?

NoneExtensiveWith assistanceIndependent riding

Medical History (ie behaviors, communication)

Has participant had (or is currently having) seizures?

YesNo

Please describe

Does participant use any assistance devices?

YesNo

Please list assisted devices:

Consent Forms

ROCK Social Media Policy:
ROCK controls what is posted on the ROCK Facebook and other ROCK social media outlets. Only those who singed Photo Releases may have photographs posted. Participant and families are asked verbal permission prior to posting. No participant names are posted. If taking pictures/videos for personal use, respect the privacy of other riders by not posting photo/videos on social media that include other participants.

Acknowledgment

Yes, I acknowledge that I have read and understand the Social Medial Policy

ROCK Authorization for Emergency Medical Treatment

Read both and select one below

Consent Plan: In the event 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 ROCK to 1)secure and retain medical treatment and transportation if needed 2)Release any records upon request to the authorized individual or agency involved in the medical emergency treatment. This authorization includes x-rays, surgery, hospitalization, medication, and any treatment procedure deemed "life-saving" by the physicians. This provision will only be involved if the emergency contacts are unable to be reached.Non-Consent Plan: I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process or receiving services while being on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedures to be followed.

Non-Consent Plan:

ROCK Confidentiality Policy:
I understand that all information, both written and verbal, regarding participants at ROCK, Ride On Center for Kids, and confidential business matters shall be held in strict confidence at all times except as needed with the facilitation for therapy and/or business purposes.

I understand that a breach of confidentiality is grounds for dismissal and may also result in legal prosecution.

I acknowledge I have read and understand the Confidentiality Policy

Yes, I have read the confidentiality policy

Liability Release:
I or my child would like to participate in the ROCK program. I acknowledge the risks and potential risks of horseback riding. However, I feel that the possible benefits to myself/son/daughter/ward are greater than the risk assumed. I hereby intending to be legally bound, for myself, my heirs, and assigns, executors or administrators, waive and release forever all claims for damages against ROCK, its Board of Directors, Instructors, Therapist, Aides, Horse Owners, Volunteers and/or Employees for any and all injuries and/or losses I/my son/daughter/ward my sustain while participating in ROCK programs. WARNING- Under Texas law(chapter 87, Civil Practice and Remedies Code), an equine professional is not liable for an injury or the death of a participant in equine activities result in from the inherent risks of equine activities.

Acknowledgement:

Yes, I have read and understand the Liability Release

ROCK Notice of Privacy Practices Acknowledgement:
I have been given the opportunity to review the ROCK, Ride On Center for Kids "Notice of Privacy Practices". This document contains a description of the uses and disclosures of my healthcare and my rights regarding such information. ROCK, Ride on Center for Kids displays the "Notice of Privacy Practices" Iin the Welcome Center.

I understand that ROCK, Ride on Center for Kids has the right to change its "Notice of Privacy Practices" and that if changes are made, a revised copy of the notice will be posted in the Welcome Center. I also understand that if I have any questions or wish to receive copies or a current copy of the "Notice of Privacy Practices"<I may contact:

Nancy Krenek and/or Shannon Middleton

2050 Rockride Lane

Georgetown, TX 78626

Telephone(512) 930-7625 Fax:(512) 863-9231

By signing this form, I am acknowledging I have read the "Notice of Privacy Practices" and agree to the uses and disclosure information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation of that is otherwise permitted by law without my specific authorization or permission. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.

Acknowledgement

Yes, I acknowledge that I have read and understand the Notice Privacy Practice.

ROCK Photo Release

I hereby

ConsentDo NOT Consent

To the use and reproduction by ROCK of any and all photographs and any other audio/visual materials taken of me/my son/daughter/ward for promotional printed material, educational activities. Exhibitions or for any other use for the benefits of the program.
The above release applies to all family members and caregivers of this participant. Contact your instructor if you have any questions about this policy.

Apriaxia	Attention Deficit Hyperactivity Disorder	Autism
Behavior Disorder	Cerebral Palsy	Developmentally Delayed
Down Syndrome	Fetal Alcohol Syndrome	Hearing Impaired
Epilepsy	Intellectual Disabilities	Learning Disabilities
Multiple Sclerosis	Muscular Dystrophy	PTSD
Scoliosis	Seizures	Spina Bifida
Traumatic Brain Injury	Visually Impaired	other