New Rider Application Please fill out the form below, if you have any questions, please email horse@hrranch.org. "*" indicates required fields Step 1 of 4 25% Participant Name* Date of Birth* MM slash DD slash YYYY Age* Height* Weight* Gender* Male Female Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Alternative Phone*Employer/School* Employer/School Phone*Employer/School Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Legal Guardian* Caregivers* Parent/Legal Guardian Address (if different from above) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Legal Guardian Phone*Referral Source* Referral Phone Number*How did you hear about the program?* HEALTH HISTORYDiagnosis* Date of Onset* MM slash DD slash YYYY Please indicate current or past special needs in the following areas:*YesNoVisionHearingSensationCommunicationHeartBreathingDigestionEliminationCirculationEmotional/Mental HealthBehavioralPainBone/JointMuscularThinking/CognitionAllergiesCommentsFrom any of the special need sections aboveMEDICATIONS*(include prescription, over-the-counter; name, dose and frequency)PHYSICAL FUNCTION* (i.e. mobility skills such as transfers, walking, wheelchair use, driving/bus riding) PSYCHO/SOCIAL FUNCTION*(i.e. work/school including grade completed, leisure interests, relationshipsfamily structure, support systems, companion animals, fears/concerns, etc.) GOALS*(i.e. why are you applying for participation? What would you like to accomplish?CONSENT PHOTO RELEASEI consent to and authorize the use and reproduction by Hope Retreat Ranch of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.* I Consent I Do Not Consent Authorization for Emergency Medical Treatment FormPhysician’s Name* Preferred Medical Facility* Health Insurance Company* Policy #* Allergies to medications* Current medications* Name Relation PhoneName Relation PhoneName Relation PhoneIn 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 Hope Retreat Ranch to: 1. Secure and retain medical treatment and transportation if needed. 2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment. Consent Plan* I consent to the statement below.This authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedure deemed “life-saving” by the physician. This provision will only be invoked if the person(s) above is unable to be reached. RIDER/PARTICIPANT RELEASE OF LIABILITY FORMConsent*The undersigned (parent/guardian completing this form), of lawful age, represents that he/she is the parent or legal guardian of (participant name filled out at the beginning of the form), a minor child, who is a rider/participant in the HOPE RETREAT RANCH EQUINE ASSISTED THERAPEUTIC RIDING PROGRAM. He/She hereby acknowledges the inherent, foreseeable, and unforeseeable risks and/or perils associated with horses, activities involving such animals , and the facilities wherein such activities are conducted. In recognition thereof, and for and in consideration of the opportunity for said minor child to ride/participate in the HOPE RETREAT RANCH EQUINE ASSISTED THERAPEUTIC RIDING PROGRAM, the undersigned does hereby for and on behalf of said minor child and his/her heirs, executors, administrators, successors and assigns, release, acquit, waive, hold harmless, and forever discharge HOPE RETREAT RANCH EQUINE ASSISTED THERAPEUTIC RIDING PROGRAM and its directors, employees , volunteers , landlords/landowners and/or agents, from any and all liability, claims, losses, actions, suits, causes of action, demands, rights, damages, costs , expenses , fees and/or compensation of any type, description or character whatsoever, which may accrue on account of said minor child’s participation as a rider/participant in the HOPE RETREAT RANCH EQUINE ASSISTED THERAPEUTIC RIDING PROGRAM. By executing this agreement, it is his/her intention to fully assume, on behalf of said minor child, all risk of bodily injury, death, or property damage occurring as a result of said minor child’s participation as a rider in the HOPE RETREAT RANCH EQUINE ASSISTED THERAPEUTIC RIDING PROGRAM. He/She further agrees to indemnify and hold harmless HOPE RETREAT RANCH EQUINE ASSISTED THERAPEUTIC RIDING PROGRAM and its directors, employees, volunteers, landlords/landowners and/or agents, from any and all liability, claims, losses, actions, suits, causes of action, demands, rights, damages, costs, expenses, fees and/or compensation of any type, description or character whatsoever, which may accrue on account of the actions, intentional, negligent, or otherwise, of said minor child, himself/herself, or his/her guest, while participating in the HOPE RETREAT RANCH EQUINE ASSISTED THERAPEUTIC RIDING PROGRAM, or while present on the premises used for said program and related activities. I acknowledge that I have read the foregoing agreement and fully understand its content.Signature*Client, Parent or Legal Guardian Date*Today’s Date MM slash DD slash YYYY Δ
