2014 Participant Enrollment Application

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1 2014 Participant Enrollment Application Participants Information Participant's Name: Date of Birth: / / Age: Weight: Height: Disability: Primary Contact Name: Phone Number: ( ) Check one: ( ) Parent ( ) Guardian ( ) Executor ( ) Other: Specify: Mailing Address: Street: City: State: Zip: Home Phone:( ) Address: Mothers Name: Cell Phone Number: ( ) Fathers Name: Cell Phone Number: ( ) Therapeutic Riding Sessions Requested: [ ] 10 Weeks [ ] 12 Weeks [ ] Indefinite Funding Pre-Arranged [ ] Yes If so with Whom? or [ ] Private / Self Pay Has the participant ever had Therapeutic Riding or Hippotherapy in the past? [ ] Yes [ ] No If yes where?

2 Primary Care Physician Info Physician Name: Phone Number: Address: City: State: Zip: Current Medications: Photo Consent Release I hereby consent and authorize Angels on Horseback to use any photographs, audiovisual materials of me/ participant for educational activities, reproduction, promotional printed material, website, exhibitions or for any other use to benefit the program. I do not consent to having the participant photographed or audiovisual taken Signature: Date:

3 Enrollment Participant Questionnaire: This questionnaire is helpful to the staff at Angels on Horseback to better understand your participation goals, interests, and understanding the participants current status. Information will be obtained and shared with staff to provide the best service possible. Please complete the following questions. Participants Name: DOB: Age: Disability: Assistance Questions: [ ] Stand alone [ ] Cannot stand [ ] Stand with assistance [ ] Use of walker [ ] Use of wheel chair [ ] Cannot sit alone [ ] Cannot sit without support [ ] Can climb stairs alone [ ] Can climb stairs with assistance [ ] Has good balance when sitting alone [ ] Needs assistance to sit [ ] Has used a lift system to hoist into bathing, toileting, bed etc. [ ] Other helpful information Sensitivities: [ ] Heights [ ] Loud Noises [ ] Certain Textures [ ] Water [ ] Dirt [ ] Helmets / Hats [ ] Fear of Falling [ ] Difficulty Following Directions [ ] Difficulty concentrating when more than one person is speaking at a time [ ] Other please Explain: Can the participant lift over 5 pounds? [ ] Yes [ ] No Some games/activities require lifting Is the participant over 160 pounds? [ ] Yes [ ] No The Therapeutic riding horses have a weight limit for the safety of riders, volunteers, staff and future participants.

4 Please describe the following: Posture: Balance: Coordinatio /Movement: Attitude/Behavior issues: Communication Challenges / Methods ( verbal, sign, pictures ) Cognitive Abilities Requires multi step instructions [ ] Yes [ ] No Balance /Perception Problems [ ] Yes [ ] No Allergies to Medications: [ ] Yes [ ] No If yes, which medications? Food Allergies: [ ] Yes [ ] No If yes, which foods? Seizure disorder: [ ] Yes [ ] No If yes, describe symptoms and what they are like Any other considerations our staff should know about or are there any special precautions? What are your goals for the riding sessions ( i.e. behavioral changes, physical improvements, attention span, verbal skills, social skills etc) What are your hobbies or interests ( i.e. baseball, dance, reading, etc.? )

5 Suggestions or comments: How did you hear about our program? [ ] Phone Book [ ] Website [ ] Friend [ ] Fundraiser event [ ] Other Signature of person completing this questionnaire: Date:

6 Participant Name: Emergency contacts: Name: Relationship: Home Phone: Work Phone: Ext: Cell Phone: Address: Name: Relationship: Home Phone: Work Phone: Ext: Cell Phone: Address: Physician's name: Phone: Health Insurance: Policy #: Preferred Medical Facility:

7 I DO I DO NOT Agree that in the event emergency medical aid/treatment is required due to illness or injury, Angels On Horseback Therapeutic Riding School (AOH) is authorized to secure and retain medical treatment and transportation if needed, including x-ray, surgery, hospitalization, medication and any treatment procedure deemed life saving by the physician. In addition, AOH is authorized to release my record upon request to any authorized individual or agency involved in the medical treatment and/or transportation of the injured party. consent to emergency medical treatment/aid in the event of illness or injury. In the event emergency treatment/aid is required, I wish the following procedure(s) to take place: Signature: Date: / / If under 18, parent or guardian: I have legal authority to sign for the above referred minor. Signature: Date: / /

8 Waiver and Release of Liability In consideration of being allowed to participate in any way at Angels On Horseback Therapeutic Riding School, Inc. (AOH), their programs, related events and activities, I acknowledge and agree that: 1) I ACCEPT THE RISKS and potential for risks of horseback riding and working with horses and activities in and around a facility where horses are kept and farm machinery operated. 2 ) I UNDERSTAND THERE IS THE POTENTIAL FOR PERMANENT INJURY including but not limited to PARALYSIS AND DEATH. 3 ) I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation. 4) I WILLINGLY AGREE TO COMPLY WITH the stated and customary terms and CONDITIONS FOR PARTICIPATION. 5) I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS AOH, their officers, officials, directors, instructors, therapists, aides, volunteers, agents, employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises, (RELEASEES), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. 6) I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS of being allowed to participate in any and all activities and programs at AOH. These activities are related to equestrian riding, farm management duties, any and all horse related activities including equine care, equine duties, and any other additional activities related thereto during my participation.. THIS RISK INCLUDES WITHOUT LIMITATION THE RISK OF NEGLIGENT INSTRUCTION AND SUPERVISION. I understand that AOH is materially relying on this waiver and assumption of risk in allowing me to participation in activities at AOH. 7) I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, related to all activities and programs. I UNDERSTAND THAT I AM REQUIRED TO WEAR A RIDING HELMET. IF FOR SOME REASON ACTING OF MY OWN ACCORD I FAIL TO WEAR A RIDING HELMET I do so on my own and without the authority of AOH and I HEREBY RELEASE AND HOLD HARMLESS AOH, their officers, officials, directors, instructors, therapists, aides, volunteers, agents, employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises (RELEASEES) WITH RESPECT TO ANY AND

9 ALL INJURY, DISABILITY, DEATH, CLAIMS, LOSS OF BODILY INJURY AND / OR PERSONAL PROPERTY. 8) I KNOWINGLY AND FREELY ASSUME ALL RESPONSIBILITIES OF ANY PERSONAL OR PROPERTY DAMAGE I may cause while at AOH. In addition I KNOWINGLY AND FREELY ASSUME ALL RESPONSIBILITY SHOULD ANY PERSONAL OR PROPERTY DAMAGE OCCUR while on any activity related events, fund raiser programs, or volunteer programs / activities that AOH holds on the premises or off the premises. I AGREE TO HOLD HARMLESS AOH FROM ANY PROPERTY CLAIMS, MEDICAL CLAIMS AND OR PERSONAL CLAIMS that may accrue. Signature: Date: / / FOR PARTICIPANTS OF MINORITY AGE ( UNDER AGE 18 AT THE TIME OF SIGNATURE) THIS IS TO CERTIFY THAT I, AS PARENT / GUARDIAN with legal responsibility for this participant, DO CONSENT AND AGREE TO HIS / HER RELEASE AS PROVIDED ABOVE of all the RELEASEES, and, for myself, my heirs, assigns, and next of kin, I RELEASE AND AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASEES FOR ANY AND ALL LIABILITIES as a result of this participant's involvement or participation in these programs as provided above, even if arising as a result of negligence EVEN IF ARISING AS A RESULT OF NEGLIGENCE. Signature: Date: / / Participants Name: ( Printed )

10 Participation Policies/ Attendance/Cancellation/Payment/Termination Attendance/ Cancellation Policy Angels on Horseback expects consistent attendance by all participants. To gain our therapeutic goals attendance is required to achieve our expectations. If you are unable to attend a regular scheduled session, notification must be made by calling Angels on Horseback at or as soon as the absence is anticipated so that we may provide sufficient notice to our staff and volunteers. Lesson times are scheduled for the same day and time each week. Please arrive early and have the participant ready with their riding helmet and gate belt on. Students who arrive late and not prepared will be docked time from there riding lesson. Everyone has a lesson time and if you arrive late the participant next in line will be waiting around and late for their lesson. It is not the responsibility for the staff or volunteers to prepare the participant prior to mounting the horse. Should AOH have to remove the participant from the active riding lesson in progress for safety, behavioral, physical, inappropriate language, hitting, kicking, spiting - there will be no makeup lesson and no refunds will be made. If the participant arrives to the facility angry, hitting or upset the participant will not be allowed to mount the horse for safety concerns of the volunteers, staff and horses. No refunds... Cancellation Policy: AOH requires a notice of cancellation for participants who will not be attending scheduled lessons. Cancellation fees are $ per lesson if not cancelled on time or not showing up for the scheduled lesson. You will be billed once a month should you not have canceled your scheduled lesson on time. AOH will be billing for unpaid cancellations, and attendance is monitored weekly. Non-payment of cancelation fee will result in termination of the participation and no refunds will be issued. Sat. Lessons - Cancellation by Wed. Wed. Lessons - Cancellation by Sun. Thurs. Lessons - Cancellation by Mon. Failure to provide proper notification will be charged a $ cancellation fee. Due to our busy schedule and limited resources, there are no make-up opportunities for missed or cancelled lessons.

11 Scheduled time off Should you know that the participant will be off from lessons in advance, you must mark the participants name on the calendar in the "Waiting Room" next to the payment box, two weeks in advance. Or place a note in the payment/note box. Failure to do so will result in a $25.00 cancellation fee. Inclement Weather / AOH Cancellation due to unforeseen circumstances: From time to time AOH needs to cancel lesson classes due to some unforeseen circumstances such as inclement weather, heavy rain, snow, ice etc. Participants who are pre-paid will have the opportunity to make up the missed lesson and no cancellation fee will apply. In the event of cancellation by AOH you will be notified by phone, cell phone or . Please make a effort if we leave a message for you to return the call or that you received the message. Payment Policy Current Riding Participants - AOH requires payment the day of service - $ per lesson unless other arrangements have been made. Monthly payments are due on the first lesson day at the beginning of the month. Participants will not receive reimbursement for missed lessons (not showing up for lessons.) New participants effective Jan 01, 2010: AOH will not be acceptting weekly payments - payment will be due in-advance, at the beginning of the first lesson day of the month. Participants will not receive reimbursement for missed lessons (not showing up for lessons.) One unnotified cancellation per session is allowed. (10 or 12 week session). Payment Plan Should you need to arrange a payment plan please contact Susan. Check Payment Policy All returned checks are subject to a $ return check fee. If a check is returned you will be notified and you will be required to pay the full amount plus the returned check fee prior to any future lesson scheduled. Payments must be placed in the payment/note box located in the " Waiting Room". Please do not give payments to volunteers. Important AOH Contact Information Phone If no one is available please leave a message. Loveamorgan@aol.com You may reach the riding instructor Susan at For cancellations on THE DAY OF LESSONS CALL Susan at cell. This way we will not have horses tacked and ready for lessons with no one to ride them.

12 Termination Policy A two week termination of services is required for all participants who ride on a regular, ongoing basis. Meaning, someone not on a scheduled session of 10 or 12 weeks but rather, weekly for an extended period of time. Failure to give a two week notification will result in payment for the full lesson missed or terminated without proper notice. If two weeks are not given and services are discontinued you will be charged for 2 full lessons totalling $ If one week notice is given you will be charged 1 full lesson fee of $ AOH has the right to terminate a participants lessons due to: inappropriate behavior issues, lack of attendance, safety regulation issues or determination made on the basis of physical, behavioral or other limitations. Payment Late Fee's Collection, Attorney and Court Fee's Failure to pay on time will result in a $ 5.00 per month late fee. If your account is 45 days past due, your account will be turned over to our collection attorney and you will be responsible for all collection, court fees, legal and lawyer fees. Acknowledgement: [ ] I have read and understand all policies regarding the participation at Angels on Horseback. Attendance, Payment, returned check, cancellation and termination policies. Date Participants Name Persons Name Acknowledging Policies Relationship

13 AOH Office Use Participant has completed the following: [ ] Completed Enrollment Application [ ] Signed Photo Consent Release or Refusal [ ] Completed Participant Questionnaire [ ] Completed Medical Form ( required by AOH Insurance for files ) [ ] Reviewed, read and understand Liability waiver Policy ( required by AOH Insurance ) [ ] Reviewed, ready and understand Termination Policy [ ] Reviewed, ready and understand Attendance / Cancellation Policy [ ] Reviewed, ready and understand Payment Policy [ ] Reviewed, ready and understand Returned check Policy [ ] Reviewed, read and understand collection fees, legal fees, and late fees Payment / Funding Source [ ] Private /Self Pay $45.00 Per lesson [ ] Funding by: Enrollment [ ] 10 Weeks [ ] 12 Weeks [ ] Indefinite Office Notes

14 Please Keep the Following 3 Pages Participants Riding Attire Participants should dress weather appropriate and always wear long pants ( even during summer classes ) with sturdy-soled boots or shoes with a 1/4 heel. No sneakers, open toed shoes, flip flops or crocks are allowed. No baggie or loose fitting shirts, slippery pants, or loose jewelry. Jackets and gloves are required for cold weather as the indoor is not heated. Riding Helmets All riders are required to wear a safety helmet that is ASTM/SEI Certified. AOH has helmets that the participant can borrow - if the rider has difficulty with wearing helmets/hats or is participating longer than 10 weeks, helmets may be purchased at Dover Saddlery and Allies Tack Shop, in North Kingstown, RI. AOH Liability Insurance regulations and policy requires that all students wear a safety helmet that is ASTM/SEI certified. No other helmet will be accepted or head injury covered if an accident occurs. Gate Belts All riding participants are required to wear a gate belt. This allows the staff and volunteers to assist with balance, sitting, standing, mounting, games and activities, while on horseback. Arriving for Lessons Lesson times are scheduled for the same day and time each week. Please arrive early and have the participant ready with their riding helmet and gate belt on. Students who arrive late and are not prepared will be docked time from their riding lesson. Everyone has a lesson time and it you arrive late the participant next in line will be waiting around and late for their lesson. It is not the responsibility of the staff or volunteers to prepare the participant prior to mounting the horse. Should AOH have to remove the participant from the active riding lesson in progress for safety, behavioral, physical, inappropriate language, hitting, kicking, spitting, reasons - there will be no makeup lesson and no refunds will be made. If the participant arrives to the facility angry, hitting or upset, the participant will not be allowed to mount the horse for the safety concerns of volunteers, staff and horses. No refunds in this case. Important Numbers: You may contact AOH at If no one is available please leave a message. Loveamorgan@aol.com You may also reach the riding instructor, Susan, at For cancellations on THE DAY OF LESSONS contact Susan at (cell)

15 (Keep This Page Continued) Payment Policy Current riding participants - AOH requires payment the day of service - $ per lesson unless other arrangements have been made. Monthly payments are due on the first lesson day at the beginning of the month. Participants will not receive reimbursement for not showing up for lessons. New riding participants - AOH will not be accepting weekly payments - payment will be due in advance at the beginning of the first lesson day of the month. Participants will not receive reimbursement for missed/not showing up for, lessons. One in advance canellation, per session, will be allowed. ( 10, 12 week session ) Payment Plan Should you need to arrange a payment plan, please contact Susan. Check Payment Policy All returned checks are subject to a $ return check fee. If a check is returned you will be notified and you will be required to pay the full amount plus the returned check fee prior to any future lesson scheduled. Payments must be placed in the payment/ note box located in the " Waiting Room behind the door ". Please do not give payments to volunteers.

16 (Keep This Page Continued) Cancellation Policy: AOH requires a notice of cancellation for participants who will not be attending scheduled lessons. Cancellation fees are $ per lesson if not cancelled on time or not showing up for the scheduled lesson. You will be billed once a month should you not have cancel your scheduled lesson on time. AOH will be billing unpaid cancellations and attendance is monitored weekly. Nonpayment of cancelation fee will result in termination of the participants participation and no refunds will be made. Sat. Lessons - Cancellation by Wed. Wed. Lessons - Cancellation by Sun. Thurs. Lessons - Cancellation by Mon. Failure to provide proper cancellation notification will result in a $ late cancellation fee. Due to our busy schedule and limited resources, there are no make-up opportunities for missed or cancelled lessons. Termination Policy A two week termination of riding services is required for all participants who are on a ongoing basis. Thus meaning someone not on a schedule session of 10 or 12 weeks. Failure to give a two week notification will result in a payment in full for a full lesson fee(s) that have been missed or terminated without proper notice. If two weeks are not given and services are discontinued you will be charged for 2 full lesson fees of $ If one week notice is give you will be charged for 1 full lesson fee of $ AOH has the right to terminate a participants lessons due to: inappropriate behavior issues, lack of attendance, safety regulation issues or determination made on the basis of physical, behavioral or other limitations. Payment Late Fee's, Collection, Attorney, and Court Fee's Failure to pay on time will result in a $ 5.00 per month late fee. If your account is 45 days past due, it will be turned over to our collection attorney and you will be responsible for all collection, court fees and legal fees.

17 2014 Angels On Horseback Annual Review/Update of Participant Information Date: Participants Name: Has any of the following information changed: [ ] YES [ ] NO Address? If Yes new address : [ ] YES [ ] NO... Phone Number [ ] YES [ ] NO... address? if yes new address: [ ] YES [ ] NO... Weight? if yes current weight [ ] YES [ ] NO... Medications? if yes current medications: [ ] YES [ ] NO... Primary Care Physician? if yes list new PCP: [ ] YES [ ] NO... Allergies? If yes to what: [ ] YES [ ] NO... Seizures.. Other information that may have changed since you completed the enrollment application? [ ] I understand and reviewed the Liability waiver policy [ ] I understand and reviewed the attendance and cancellation policy [ ] I understand and reviewed the Payment Policy [ ] I understand and reviewed the Termination Policy [ ] I understand and reviewed the late fees, collections fees, Attorney and Court Fees Signature of person completing form: Date:

Able-bodied Riding Application Packet 2018

Able-bodied Riding Application Packet 2018 Welcome to the Ivey Ranch Equestrian Program! We are looking forward to your participation in this fun and exciting program and invite you to contact the office