NCTRC Client Intake/Participant Form

NCTRC Client Intake/Participant Form
The Riding Center is committed to recognizing the rich diversity of our clients. Much of the demographic information we collect is used in a batched format on funding requests that allow us to keep costs affordable. No personally identifiable information is shared, and we do not share personal information outside of our organization. If you have any questions about any of the information we are collecting, please don't hesitate to discuss with us.

Please don't be alarmed by the length of the form - we serve clients with a variety of needs and want to ensure that we have all of the information to ensure maximum safety and benefit from our services; many of the questions won't apply for any one individual, and the average time to complete the form is 20 minutes.
Date

MonthDayYear
Date
Applicant/Participant
Name*

First NameLast Name
Nickname (optional)
Primary Diagnosis*
Secondary Diagnosis
Additional Diagnoses
DOB (Date of Birth)*

MonthDayYear
Date
Age
Applicant/Participant Age in Days
Gender*
Ethnicity*
Height (in inches)*
Please round up if needed.
Weight*
Please note that for the safety of our horses, we do have a 200 lb weight limit for mounted activities. However, we are able to offer ground-based equine activities to clients of any weight.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence*
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email
example@example.com
Caregiver Information

If the applicant/participant is an adult legally responsible for themselves, click here to skip this section.
Parent/Guardian #1

First NameLast Name
Parent/Guardian #1 Relationship to Applicant
Parent/Guardian #1 Address (if different from applicant's above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #1 Cell Phone (if different from above)
Parent/Guardian #1 Email (if different from above)
example@example.com
Parent/Guardian #2

First NameLast Name
Parent/Guardian #2 Relationship to Participant
Parent/Guardian #2 Address (if different from applicant's above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2 Cell Phone (if different from above)
Please enter a valid phone number.
Parent/Guardian #2 Email (if different from above)
example@example.com
The North Carolina Therapeutic Riding Center (NCTRC) empowers children and adults with physical, mental, emotional and social challenges to create more active, healthy and fulfilling lives through equine assisted activities and therapies.

Communication and Learning Style
Does the Applicant/Participant have the ability to understand, to express wants and needs and communicate with peers socially?

YesNo
If the Applicant/Participant has needs in this area, what strategies are currently being used and which are most beneficial?
Is the Applicant/Participant able to follow directions, understand abstract concepts and read?

YesNo
If there are needs in this area, what approaches are currently most helpful?

Please list 2-3 areas of Applicant/Participant's strengths
Please list 2-3 areas of functional deficits (self-care, mobility, safety) that need improvement:
What things are most motivating to the Applicant/Participant?
Applicant/Participant's Current Services (Please check all that apply)

Physical TherapyOccupational TherapySpeech TherapyAdaptive/Therapeutic Riding/SportsMental/Behavioral Health ServicesOther (ABA, vision therapy, etc.)
Where does the Applicant/Participant receive other services and how often?
What are the Applicant/Participant's current goals in the other services?

Applicant/Participant's Assistance Requirements Does applicant/participant require assistance in the following areas:

DressingToiletingFeedingBathingHygiene & groomingTransfer & mobility
Please describe the level of assistance needed in any area checked.
The North Carolina Therapeutic Riding Center (NCTRC) empowers children and adults with physical, mental, emotional and social challenges to create more active, healthy and fulfilling lives through equine assisted activities and therapies.

Consents and Releases
Liability Release
Whereas, the Undersigned desires to participate in the horse-centered programming conducted by NC Therapeutic Riding Center, Inc. (“Riding Center”) and hereby acknowledges his or her understanding of the inherent risks involved in riding and being proximate to horses, which risks include bodily injury, disability or death from accidents incurred while using, riding, or being proximate to horses; and further acknowledges that both horse, client, staff, and volunteers assisting with horse-centered activities can be injured in normal use or in competition and schooling.

In consideration for being permitted to participate in activities conducted by the Riding Center, I hereby agree that I, my heirs, my distributees, guardians, legal representatives and assignees will not make a claim against, sue, attach the property of, lean or prosecute the Riding Center, their landlords, directors, officers, members, employees or assignees, for any claim I now have or may hereafter have for death, injury, disability, property loss, or property damage resulting from my participation in activities conducted by the Riding Center, whether caused by my acts of omission or anyone else’s negligence. In addition, it is understood that any and all insurance that I have shall be primary. To the fullest extent permitted by law, I shall defend, indemnify & hold harmless the NC Therapeutic Riding Center and the landlord, and directors, officers, agents and employees of the Riding Center for and against any and all claims, damages, losses, expenses and liabilities of every kind, including but not limited to attorney’s fees, in any way arising out of or in connection with my activities under this Agreement. This indemnification shall apply regardless of any active and/or passive negligent act or omission of the NC Therapeutic Riding Center or the landlords, directors, officers, agents and employees of the Riding Center.

I DO EXPRESSLY CONSENT TO ASSUME ANY RISK, CHANCE OF HARM, PERSONAL OR REAL PROPERTY DAMAGE, INJURY, SUFFERING, DISABILITY OR DEATH INVOLVED WITH OR RESULTING FROM MY/MY CHILD'S PARTICIPATION IN PROGRAMS CONDUCTED BY THE RIDING CENTER.

WARNING

Under North Carolina law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting exclusively from the inherent risks of equine activities. Chapter 99E of the North Carolina General Statutes.

I have carefully read this agreement and release and fully understand its contents. I am aware that this is a Release of Liability, a waiver of legal rights and contracts between me and the NC Therapeutic Riding Center. I sign this agreement and liability of my own free will. I further acknowledge that there are no warranties either express or implied, concerning the facilities, events or activities at the NC Therapeutic Riding Center.
Date

MonthDayYear
Date
Applicant/Participants Signature (or signature of parent/guardian if Applicant/Participant is under age 18 years)*

Clear
Signer's Name

First NameLast Name
Consent for Emergency Medical Treatment
In the event emergency medical aid/treatment is required due to illness or injury while participating in the service of, or while being on the property of the North Carolina Therapeutic Riding Center (NCTRC), I authorize NCTRC to secure and retain medical treatment and/or transportation if needed. This authorization includes but is not limited to x-ray, surgery, hospitalization and medication. In addition, I authorize NCTRC to release my/my child's/my ward's records to any individual involved in medical treatment and/or necessary transportation.
Applicant/Participant Name

First NameLast Name
Emergency #1 Contact
Emergency Contact #1 Phone Number
Please enter a valid phone number.
Emergency Contact #1 Relationship to Applicant/Participant
Emergency #2 Contact
Emergency Contact #2 Phone Number
Please enter a valid phone number.
Emergency Contact #2 Relationship to Applicant/Participant
Physician's Name
Physician's Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Date
Applicant/Participant Signature (or signature of parent/guardian if Applicant/Participant is under age 18 years)

Clear
Signer's Name

First NameLast Name
Audio-Visual Release
Check one

I hereby consent to and authorize the use and reproduction by the North Carolina Therapeutic Riding Center of any and all photographs and any other audiovisual materials taken of me/my child/my ward for promotional printed material, educational activities or for any other use for the benefit of the program.I do not consent to the above use of photo or videographic materials.
Applicant/Participant Signature (or signature of parent/guardian if Applicant/Participant is under age 18 years)

Clear
Signer's Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

NCTRC Client Intake/Participant Form

Applicant/Participant

Caregiver Information

Health History - Motor Skills

Health History - Orthopedic

Health History - Medical

Health History - Other

Communication and Learning Style

Consents and Releases

Liability Release

Consent for Emergency Medical Treatment

Audio-Visual Release