JRC PREP NEW CLIENT APPLICATION

JRC PREP NEW CLIENT APPLICATION
Applicant Information
Name *

First Name Last Name
Date of Birth *

Month Day Year
Gender

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Height
Weight
Applicant Phone Number (if applicable):
Phone number including area code
Applicant Email (if applicable):
example@example.com
Documented Disability: *
Parent/Guardian Information
Mother/Legal Guardian: *
Home Address (if different than above):
Mother Preferred Email Address: *
example@example.com
Mother Preferred Phone Number: *
Phone number including area code
Mother Occupation/Name of Company:
Father/Legal Guardian:
Father Home Address (if different than above):
Father Preferred Email Address:
example@example.com
Father Preferred Phone Number:
Phone number including area code
Father Occupation/Name of Company:
Caregiver Name (if applicable):
Caregiver Phone:
Phone number including area code
Who should we call to inform you of cancellations? *
In the event of an emergency and parent/guardian cannot be reached, contact
Emergency Contact Name: *
Emergency Contact Phone: *
Phone number including area code
Emergency Contact Relation: *
Preferred emergency medical facility or nearest: *
Names/Ages of Applicants Siblings, if applicable
How did you hear about the JRC Prep Day Program?
Have you attended a tour of JoyRide Center? *

Yes No

PLEASE ANSWER THE FOLLOWING QUESTIONS:
Please describe the applicant’s general health, including special medical problems and/or physical disabilities: *
Please describe the applicant's communication abilities: *
Please describe the applicant's social/emotional state most of the time (for example, withdrawn, hyper-verbal, frustrated, sociable, even-tempered, etc.): *
Does he/she prefer to be with peers, family, someone older, younger, or alone? Please explain: *
Please describe the applicant’s self-help skills (What does someone need to do daily to help the applicant?) *
Please describe the applicant's daily routines and free time activities: *
What do you see to be the applicant's functional disabilities? *
What do you think the applicant feels are his/her disabilities? *
What are the applicant's specific aptitudes, interests, and/or strengths? *

Has the applicant ever been involved with any of the following?

	NO/YES	Explain
Tobacco
Drug Abuse
Criminal Activity
Sexual Misconduct

Please describe activity areas and/or situations that the applicant strongly dislikes: *
Please describe activity areas and/or situations that the applicant enjoys: *
Please describe your goals and expectations for the applicant and what you hope JRC Prep can accomplish: *

LIABILITY RELEASE: I/my child/my ward would like to participate in the JoyRide Center, Inc. program. I acknowledge the risks and potential risks of 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 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.death of a participant in farm animal activities resulting from the inherent risks of farm animal activities.
Signature of parent/guardian/applicant (if applicable): *

Clear
Date: *

Month Day Year
Date
PHOTO RELEASE: I hereby *

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 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/caregiver.
Signature of Parent/Guardian/Client (if appropriate) *

Clear
Date: *

Month Day Year
Virtual Lesson/Distance Learning Recording

If I/my child chooses to participate in Distance Learning video lessons, I understand that these lessons conducted through Google Meet, Zoom or other similar type applications will be recorded and distributed to other JRC Prep clients via email. If you do not wish your image to be included on the video lesson, it is your responsibility to disable the camera during video lessons.
Virtutal Lesson/Distance Learning Recording Permission - Signature of Parent/Guardian/Client (if appropriate) *

Clear
Date *

Month Day Year
Date
The above releases apply to all family members & caregivers of this client. Contact your instructor if you have any questions about this policy.
BILLING INFORMATION
JoyRide invoices are normally emailed around the first of each month for services rendered in the previous month. Payment is due upon receipt and considered late if received after the 15th of the month.
Email bills to:
example@example.com
I prefer to have bills MAILED to me. Please mail them to the following address:
I understand that I will be charged my regular daily tuition fee if I cancel or do not show up for a session. There will be no charge for classes cancelled by JoyRide.
I have read and agree to abide by all JoyRide guidelines and policies included in this form. *

YES
Signature of parent/guardian/client (if applicable): *

Clear
Date: *

Month Day Year
Date

Acknowledgement of Notice of Privacy Practices
Please read the following Notice of Privacy Practices:
I acknowledge receipt of the 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)
Representative Relationship to Client

Parent or guardian of unemancipated minor Court appointed guardian Executor or administrator of decedent's estate Power of attorney
Today's Date *

Month Day Year
Date
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:

	NO/YES	Explain
Headaches
Asthma
Heart Trouble
Kidney Disease
Stomach Trouble
Diabetes
Neurological Problems
Emotional Problems
Behavioral Problems

JRC PREP NEW CLIENT APPLICATION

Applicant Information

Parent/Guardian Information

Schools/Programs Attended

PLEASE ANSWER THE FOLLOWING QUESTIONS:

MEDICAL HISTORY

Allergies/Restrictions

History of Illness/Hospitalization/Surgery

Seizure Activity

Health History

BILLING INFORMATION

Acknowledgement of Notice of Privacy Practices