Taste of TROT Summer Camp

Applicant Information

Participant First Name

Participant Last Name

Address

City

State

Zip

Preferred Phone

DOB

Gender

Race and Ethnicity

Is the participant a dependent of a Veteran/First Responder?

Is the Participant a Veteran/First Responder

If yes, what branch of service?

Are you affiliated with the Wounded Warrior Project?

YesNo

Personal Health Information

Age

Weight

Height

Primary Diagnosis

Secondary Diagnosis

Mobility Status (Walks unassisted, uses assistive devices, etc.)

Communication (Verbal, non-verbal, signs)

Behaviors (Impulsive, fearful, frustration tolerance)

Medications taken

Seizures (if applicable please describe)

Please describe any limitations

Allergies, Asthma, etc.

Skin Sensitivity

Participant's occupation/school grade level

Personal Goals

Other

Availability

Please select the week that works best for your schedule:

Week 1 | July 10-13 (VETERANS FAMILIES ONLY)Week 2 | July 17-21Week 3 | July 24-28

Referred by:

Parent/Guardian Information

Parent/Guardian Name (1)

Relationship to Participant

Cell Phone

Work Phone

Parent/Guardian Name (2)

Relationship to Participant

Cell Phone

Work Phone

Medical Emergency Contact Information

In the event of a medical emergency, TROT will provide basic first aid and/or call 911 and will disclose all available health care information to emergency medical personnel.

Best Emergency Contact Name

Phone

Other Phone #

Relationship to Participant

Preferred Medical Facility

Physician's Name

Health Insurance Company

Policy #

Reasons for Discharge of Participant

Please be advised of the following reasons that may lead to discharge from the adaptive riding program and/or the center.
1) The client has reached all of their goals and is ready to graduate.
2) The client's potential to maintain head and neck control while riding presents a safety concern.
3)The inability to follow directions is interfering with progress towards goals.
4) Uncontrolled and/or inappropriate behavior that constitutes a safety risk to a client, staff, volunteer, and/or horse.
5) The client exceeds weight staff, volunteers, and/or horses can safely manage.
6) Any change in the client's medical, physical, cognitive, or emotional condition that makes adaptive riding inappropriate.
7) Three scheduled appointments are missed without prior cancelation.
8) Disruptive behavior that is counterproductive to the benefit of anyone, equine or human at TROT.
9) Any purposeful act of compromised safety related to any equine, human or self at TROT.
10) No longer suited, willing or able to preform activities at TROT safely or as directed.
11) Non-payment of fees, as originally agreed.

Procedure:
a) All participants/volunteers/guests who meet the criteria of dismissal will be asked to meet with the Volunteer Coordinator and Program Director to discuss the behavior/issue in question.
b) The Volunteer Coordinator and Program Director will work to educate and outline the appropriate expected behavior of the participant/volunteer/guest at TROT.
c) If the participant/volunteer/guest is willing to perform the expected behavior/task, then support and further education will be implemented by the TROT staff.
d) If the participant/volunteer/guest is not receptive to the expectation of behavior, the volunteer will be asked to leave the TROT program. Therefore, dismissed from the TROT property or returning in the future without permission.
e) The participant/volunteer/guest will be sent a signed, dated letter confirming the expected actions as a result of the meeting.
f) An additional copy of the letter will be Printed and placed in the participant's/volunteer's file.

Reasons for Discharge Consent

I Understand and agree to TROT's Discharge Policy.

Participant Liability, Confidentiality Agreement, Photo and Video Release

Liability Release: I acknowledge the risks and potential risks for horseback riding and activities in and around a facility where horses are kept, and farm machinery operated. However, I feel that the possible benefits to me/child/my ward are greater than the risk assumed. Intending legally to bind myself, my heirs, and assigns, executors or administrators, I hereby waive and release forever all claims for loss or damages of any kind against TROT, its Board of Director, Instructors, Therapists, Aids, Volunteers and Employees for al and all injuries and losses that I/my child/my ward may sustain while participating in the TROT program. This release includes without limitation the risk of negligent instruction and supervision. I engage in activities at TROT voluntarily with knowledge of the risks and I assume all risks of injury, death, and property damage that may result. I agree to bear any loss myself. I acknowledge that TROT and the property owners are materially relying on this waiver and assumption of risk allowing me/my child/my ward to participate in activities at TROT.

Liability Release Consent

I agree to the TROT Liability Release Agreement

Confidentiality Agreement: I understand that all the personal information (written and verbal) about participants at TROT is confidential and not to be shared with anyone without expressed written consent of the participant of their parent/guardian if a minor.

Confidentiality Agreement Consent

I agree to the TROT Confidentiality Agreement

Photo and Video Release: The use and reproduction by TROT of any audio/visual materials taken of me/my child/my ward for distribution to the public for promotional printed materials, educational activities or for any other use for the benefit of the program.

Photo and Video Release

I DO consent to TROT's Photo and Video Release.I DO NOT consent to TROT's Photo and video Release

Taste of TROT Summer Camp - July 2024