2021 JoyRide Horsemanship Program New Client Registration Form

JoyRide Center Horsemanship Program New Client Registration Form
Welcome to our electronic JoyRide Horsemanship New Client Registration Form. Before filling out this form, you should have done the following:

1. Speak with an instructor/therapist at JoyRide to insure JoyRide Center is a good fit for you. Call the office at 281-356-5900.

2. Read our Client Information Packet on our website, www.JoyRideCenter.org, "Programs>Client Information" page, for an overview of our programs and information about rates and policies. You will be asked in this registration form to confirm that you have read the Client Information Packet.

If you have done both of the above, and the instructor/therapist has told you to go ahead and fill out the registration form, proceed with this electronic form.

There are 14 pages and it should take approximately 15-30 minutes to complete. If you need to stop and finish the form later, click SAVE FOR LATER. When you get to the last page, don't forget to press SUBMIT.

In addition to this form, the following will also need to be submitted. You can find these forms on the JRC website, www.JoyRideCenter.org , Programs>Client Information page.
1. Medical History/Physician's Statement - to be filled out and signed by your doctor - REQUIRED FOR ALL and MUST BE RECEIVED AT JRC BEFORE AN EVALUATION CAN BE SCHEDULED!
2. Prescription for Therapy - to be signed by doctor - REQUIRED FOR ALL
3. (Optional) Top Hands Horse Show Medical form - to be filled out and signed by doctor -REQUIRED ONLY FOR CLIENTS COMPETING IN THE TOP HANDS SHOW
4. (Optional) Special Olympics Medical form - to be filled out and signed by doctor - REQUIRED ONLY FOR CLIENTS COMPETING IN SPECIAL OLYMPICS
5. (Optional) Tuition Assistance Application - if applicable, to request a discount on JRC tuition. Ignore the deadline on the form. We can accept new Tuition Assistance applications any time.
At the end of this form you will find a place to upload the above completed forms, so you may want to wait and get them all filled out/signed before you submit this electronic form. But, you may send them in separately if you prefer.

Upon receipt of the forms, we will contact you to schedule an evaluation by one of our therapists. EVALUATIONS WILL NOT BE SCHEDULED UNTIL WE HAVE RECEIVED THE REGISTRATION FORM AND THE MEDICAL HISTORY/PHYSICIAN'S STATEMENT.

REGISTRATION
Today's Date: *

Month Day Year
Client Name *

First Name, Middle Initial Last Name
Nickname
Date of Birth *

Month Day Year
Address to use for JRC correspondence: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County: *
Client School/Employer :
Parent/Guardian Information
Mother/Guardian Name *

First Name Last Name
Mother Phone *
Mother Phone
Mother Address (if different than above):
Mother Email *
example@example.com
Mother Employer/ Occupation:
Father/Guardian:
Father/Guardian Name

First Name Last Name
Father Phone Number
Father Phone
Father Address (if different than above):
Father Email:
example@example.com
Father Employer/Occupation:
Caregiver (if applicable):
Caregiver Phone Number:
Caregiver Phone
Who should we call to inform you of class cancellations? *
Name (and ph # if not elsewhere on this form)
How did you hear about JoyRide?
In the event of an emergency and parent/guardian cannot be reached, contact:
Emergency Contact Name: *
Phone Number *
Emergency Contact Phone
Relation: *
Preferred Medical Facility - or nearest *

RELEASES
Liability Release:
I/my son/my daughter/my ward would like to participate in the JoyRide Center, Inc. program. I acknowledge the risks and potential risks of horseback riding and working around or near farm animals. However, I feel that the possible benefits to myself/my son/my daughter/my 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 JoyRide Center, Inc., its Board of Directors, Instructors, Therapists, Aides, Horse Owners, Volunteers and/or Employees for any and all injuries and/or losses I/my son/my daughter/my ward/other family members may sustain while participating in JoyRide programs. WARNING - Under Texas law (Chapter 87, Civil Practice and Remedies Code), a farm animal professional is not liable for an injury to or the death of a participant in farm animal activities resulting from the inherent risks of farm animal activities.
Date *

Month Day Year
Signature of Client/Parent/Guardian *

Clear
Photo Release:
I hereby (Check one) *

Consent Do NOT Consent
to the use and reproduction by JoyRide Center of any and all photographs and any other audio/visual materials taken of me/my son/my daughter/my ward/other family members for promotional printed material, educational activities, exhibitions or for any other use for the benefit of the program. JoyRide policy is that only first names will be used to identify people unless specific permission is given from the parent/client/guardian.
Date *

Month Day Year
Signature of Client/Parent/ Guardian *

Clear

BILLING INFORMATION
Invoices are emailed to the person designated below the first week of the month for charges in previous month. Please check if you prefer them to be mailed via USPS.
How do you prefer to receive JRC bills? *

Email Mailed via USPS
Who should we email bills to?
Person's name
Email Address:
example@example.com
Please mail bills via USPS to:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please select how tuition will be paid. *

Private Pay: I understand that I will be charged an Absence Fee equal to my regular class tuition fee if I cancel or do not show up for a lesson/session. There will be no charge for classes cancelled by Joyride. A Service Provicer will pay my tuition: I understand that if I am absent more than 3 times per semester, JoyRide will have to assess if we can continue providing services.
For Service Provider clients - my tuition is paid by:

Scoggins Astrocare OTHER
I have read and agree to abide by all JoyRide guidelines and policies included in the Client Information packet, which can be found at www.JoyRideCenter.org. Please Initial. *

CLIENT GOALS/SKILLS/HEALTH HISTORY
Diagnosis: *
Date of Onset: *

Month Day Year
GOALS (i.e. What would you/your rider like to accomplish this year?) *
MEDICATIONS (include prescription, and OTC, name, dose and frequency): *
HEALTH HISTORY (surgeries, additional diagnosis, etc.) *
PHYSICAL FUNCTION (mobility skills, transfers, walking, wheelchair use, driving, etc.) *
PSYCHO/SOCIAL FUNCTION (work/school including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc.) *
Does client participate in any other therapies? *

YES NO
Please list CURRENT THERAPY SCHEDULE.

SEIZURE INFORMATION

Acquiring the following information is required by PATH, Intl.
Any changes in seizure activity in the last year? *

YES NO
Does medication cause photosensitivity? *

YES NO
Have you ever had a seizure? *

YES NO
If YES, please fill out the following:
Type of seizure for most common type:
Typical aura (pre-seizure sensations or behaviors):
Typical motor activity during the seizure:
The post seizure behavior and duration:
The average duration of the seizures:
The current frequency of seizures:
What to do should a seizure occur at the center/does the rider need to get off the horse?
Date of last seizure:

Month Day Year
Type of seizure for 2nd most common type:
Typical aura (pre-seizure sensations or behaviors):
Typical motor activity during the seizure:
The post seizure behavior and duration:
The average duration of the seizures:
The current frequency of seizures:
What to do should a seizure occur at the center/does the rider need to get off the horse?
Date of last 2nd type of seizure:

Month Day Year
Any other information JoyRide staff should know about seizures:
Client/Parent/ Guardian Signature: *

Clear
Date *

Month Day Year

JoyRide Competition/Horse Show Opportunities for 2021-2022
We hope to have several exciting opportunities for showing this coming competition year. Please sign up for the competitions you would like to participate in on the form below, or choose no competitions. We will make every effort to accommodate everyone who is interested in showing, but our capacity is driven by our horse and volunteer availability.

JoyRiders must be 8 yrs. or older and holding reins to participate in shows. See specific requirements for some shows. Most shows will be limited to 15 or less riders.

The following is a list of the shows, and dates for the shows in which JoyRide will hopefully be participating.

Ft. Bend Show - TBD. Show Fee: $80

JoyRide Trick or Trot Horse Show – Saturday, October 23, 2021 at JoyRide Center. Show Fee: $60.

Top Hands Horse Show – This show will be in late February, 2022 at Reliant Arena. Specific dates and times to be determined later in the year. Riders must have a Top Hands medical form signed by a physician. Download it at www.JoyRideCenter.org, Clients and Programs tab. Show Fee: $185

Area/Regional Special Olympics- April, 2022, held at the Lone Star Cowboy Church in Montgomery, TX. Specific dates and times to be determined early next year. Riders must have a current Special Olympics Medical, signed by a physician. Download it at www.JoyRideCenter.org, Clients and Programs tab. Show Fee $75.00

State Special Olympics- May, 2022. Brazos County Expo Center, Bryan, TX (riders must have competed at Area Special Olympics and be 12 yrs. or older to participate). Show Fee: $185. www.sotx.org

Show fees are not covered by Service Providers or Inspiring Hands.

If you have questions please contact JRC.

Please keep this information for your records. Go Team JoyRide!
Please check one: *

YES, I would like to participate in competitions. NO, I will not be participating in competitions.

COMPETITION SIGN-UP FORM
Name *

First Name Last Name
Date of Birth *

Month Day Year
Age as of Jan 1, 2021: *
Check shows that you would like to participate in: *

Trick or Trot Horse Show, Sat., October 23, 2021 (Fee: $60) Top Hands, February, 2022 (Fee: $185) Area/Regional Special Olympics, April, 2022 (Fee: $75) State Special Olympics, May, 2022 (Fee: $185)
Please Initial: I understand that JoyRide may have to limit the number of JoyRiders at each show to 15 or less riders. If JRC has to limit the number of riders it will be based on horse and volunteer availability and may require a ‘draw’ from class level and horse choices.Show Fees are not covered by Service Providers or Inspiring Hands *
Please Initial: NEW THIS YEAR! Show fees will be billed the month preceding the show. Please let your instructor know at least a month before the show if you will not be attending the shows you sign up for. *
Date: *

Month Day Year

GETTING TO KNOW YOU

This page will be put in a notebook that the volunteers can read to learn a little about the clients they will be working with.
Today's Date

Month Day Year
Date
Client Name

First Name Last Name
You can download a photo below or email one to contactus@JoyRideCenter.org (optional).
Browse Files
Download Photo Here Cancel of
Please call me (name I go by)Name I go by .
I am age years old.
I began participating at JoyRide on   Date   .
My family members are   family members
My pets are   pets
My interests and hobbies are   interests & hobbies
My JoyRide goals are   JoyRide goals
(Optional) Supply any details about the client you think might be helpful to the volunteers who will be working with him/her/you. (speech, vision, comprehension)
Particular methods that this client responds to:

Please read the following Notice of Privacy Practices then sign acknowledgement on next page.

Acknowledgement of Receipt of Notice of Privacy Practices
Client Name *

First Name Last Name
I hereby acknowledge that I have received a copy of JoyRide Center's Notice of Privacy Practices. I understand that I have the right to refuse to sign this acknowledgement if I so choose. Signature of Client or Legal Representative *

Clear
Printed name of client's representative (if applicable):
Relationship to Client (if applicable):

Parent or guardian of unemancipated minor Court appointed guardian Executor or administrator of decendent's estate Power of Attorney
Date *

Month Day Year
Date

Thank you for filling out our registration form. Don't forget to also go to our website, www.JoyRideCenter.org, "Programs>Client Information" page, to download the following.
1. Medical History/Physician's Statement - to be filled out and signed by your doctor - REQUIRED FOR ALL. MUST BE RECEIVED AT JRC BEFORE AN EVALUATION CAN BE SCHEDULED!
2. Prescription for Therapy - to be signed by doctor - REQUIRED FOR ALL
3. (Optional) Top Hands Medical form - to be filled out and signed by doctor -REQUIRED FOR CLIENTS COMPETING IN THE TOP HANDS SHOW
4. (Optional) Special Olympics Medical form - to be filled out and signed by doctor - REQUIRED FOR CLIENTS COMPETING IN SPECIAL OLYMPICS
5. (Optional) Tuition Assistance Application - to request a discount on JRC tuition.
You may upload any of the above completed forms here to be submitted with your registration OR send them later by email, fax or mail.

Browse Files
May upload multiple documents. Max 100 MB per document Cancel of
Press PRINT FORM before submitting if you would like to save a copy of this form.

Press SUBMIT when you are ready to send it to JoyRide.
Should be Empty:

JoyRide Center Horsemanship Program New Client Registration Form

REGISTRATION

Parent/Guardian Information

Father/Guardian:

RELEASES

Liability Release:

Photo Release:

BILLING INFORMATION

CLIENT GOALS/SKILLS/HEALTH HISTORY

SEIZURE INFORMATION

JOYRIDE CLASS AVAILABILITY

Fall 2021 or Spring 2022 Semester

JoyRide Competition/Horse Show Opportunities for 2021-2022

GETTING TO KNOW YOU

IT TAKES A VILLAGE (or a Barnful!)

Affiliations

Acknowledgement of Receipt of Notice of Privacy Practices