Updated 2022 Recreational Horsemanship Application

Participant Information

Please be as thorough with your answers as possible. The more we understand about you, the better we can serve you! As a nonprofit organization, we rely heavily of grants that require us to report demographic information about our participants. Thank you for providing this information so that we can continue to provide our high-quality programs at the lowest cost possible. All information is protected by our confidentiality policy.
Name

First Name Last Name
Please share your pronouns
Date of Birth *

Month Day Year
Age *
Diagnosis: Primary *
Diagnosis: Secondary
Gender *
Sex
Height *
Weight *
Primary Phone (please tell us if it is cell or home ) *
Email Address
Street Address *
City *
Zip Code *
School/Institution/Employer Name *
Is the participant on an IEP *

Yes No
Please attach a copy of the IEP here. This helps us better support each participant by aligning horsemanship goals with IEP goals.

Browse Files

Cancel of
Does the participant wear a mask?

Yes No
Is the Participant a *

Minor Adult with Legal Guardian or Caregiver Independent Adult Veteran
Are there children in foster care currently residing in the home? *

Yes No
Does the participant speak a language other than English at home? *

Yes No
Does the participant's household qualify for Oregon’s free/reduced lunch program? *

Yes No
What is the Participant's racial/ethnic background? *

Asian Middle Eastern Black/African American Native American/Alaskan Native Caucasian/White Pacific Islander Hispanic/Latino Other
Is the participant considered part of a vulnerable, underserved or underrepresented population? (Vulnerable and underserved populations generally include the economically disadvantaged, experiencing homelessness, low-income, racial and ethnic minorities, members of the LGBTQ+ community, youth with trauma related adverse childhood experiences, children with incarcerated parents, or individuals experiencing physical or mental challenges.) *

Yes No
For minors or adults with legal guardians/caregivers:
Parent or Guardian Name
Phone Number

Area Code Phone Number
Employer
Email Address
Other Parent or Guardian Name
Phone
Employer
Email
Name any caregivers and their phone numbers who may transport or be responsible for the participant
Who can we thank for telling you about us?
Individual Name:
Agency/Organization Name:
What is the participant's experience with horses?

None A Little Lots
Health History
Please list all medication (including medical marijuana) *
Please note any allergies and if EpiPen or inhaler is used
Does participant have a history of seizures? *

Yes No
If yes, please answer the following questions.
Type of seizure
Date of last seizure

Month Day Year
Frequency of seizures
Duration of seizures
Indicators of oncoming seizure
Triggers
Typical recovery time
*Healing Reins automatically calls 911 in cases of seizures lasting over 2 min. or multiple seizures in a short time frame
Physical Abilities
Is the participant proficient in the following areas? Please check all that apply: *

Sits without assistance Stands without assistance Climbs without assistance Holds objects Walks without assistance Runs without assistance
Please list and explain ANY assistive devices that the participant utilizes at home, work or school (include hearing, communication and visual):
Sensory Concerns
Please describe any sensitivity in the following areas

Visual (seeing) Auditory (hearing) Olfactory (smelling) Tactile (touch)
Comments:
Cognition and Processing: check all boxes that apply
Educational/Cognitive

Knows numbers Knows letters Knows left/right Knows prepositions Communicates feelings Makes choices
Social

Recognizes name Makes eye contact Waves/says hello/bye Shares toys/items Knows safety awareness Interacts with peers Appropriate conversation Takes turns
Language

Makes sounds Says words Combines 2 or more words Speaks in complete sentences Understands “No” Letter sound identification Signs or uses gestures Uses picture symbols
Follows simple directions

1 Step 2 Step 3 Step Complex
Attention to task

Poor (0-1 min) Fair (1-5 min) Average (5 min)
Frustration tolerance

Poor Fair Average
Problem solving

Poor Fair Average
Learning Style

Visual - learns by watching Auditory – learns by hearing Kinesthetic – learns by doing
“Do’s” and “Don’ts” for this participant/your family
Anything else we should know?
Please list any goals you have for participation *
Mental Health: Please check boxes that apply
Thoughts/Feelings/Mood

Anger/frustration/hostility Attention, concentration Confusion Depression Disliking others Emptiness Euphoria Excessive worry Failure Fatigue Fear Grieving (death, loss, divorce, etc) Guilt Hearing things other people don’t Homicidal thoughts Intrusive thoughts Judgment problems Memory difficulties Negative thoughts Obsessive thoughts Oversensitivity to criticism Oversensitivity to rejection Panic attacks Perfectionism Sadness Seeing things other people don’t Self-centeredness Self-esteem Shyness Spiritual, religious, or moral issues Stress Sudden mood changes Suicidal thoughts Suspiciousness Temper problems Thoughts of hurting self or others
Behavior

Aggression, violence Alcohol use Argumentative Avoidant Compulsive behavior/rituals Controlling Decreased/lack of sexual interest Dependency Destruction of property Drug use counter Eating problems Financial problems, debt Gambling Hyperactivity Internet problems Irresponsibility Isolation Legal problems Letting others take advantage you Lying Not able to relax Pornography Preoccupation with sex Procrastination Purging Self-destruction/sabotaging Self-neglect Sexual dysfunction Smoking Stealing Threats Weight gain or loss Withdrawal from others Loss of interest in things liked Sleep difficulty Loss of appetite Overeating Fire starting Bed wetting
Family & Relationships

Affair Childhood issues (your childhood) Divorce Friendships Housework/chores Interpersonal conflicts Parenting Problems with child(ren) Problems with parents Problems with spouse/partner Separation
Abuse

Abuse of alcohol Abuse of drugs Emotional abuse by another Emotional abuse of another Financial abuse Neglect Physical abuse by another Physical abuse of another Sexual abuse by another Sexual abuse of another Verbal abuse Animal abuse
Work & School

Absenteeism Career concerns, goals, choices Difficulty with coworkers Difficulty with supervisor Performance Tardiness Procrastination
The information provided is, to my knowledge, accurate and current. I have received and read the Participant Handbook.
Electronic Signature: *
I am (check one): *

Participant Participant's Parent Participant's Legal Guardian
Date: *

Month Day Year
Participant Consent & Release Form

CONSENT FOR EMERGENCY MEDICAL TREATMENT: In the event of an emergency, if medical aid/treatment is required due to illness or injury while participating in the services of, or while being on the property of, Healing Reins Therapeutic Riding Center (“HRTRC”), an Oregon non-profit corporation, I authorize HRTRC to secure and retain medical treatment and/or transportation if needed. This authorization includes any treatment deemed necessary by a treating health care professional and includes, but is not limited to, x-ray, surgery, hospitalization, and medication. In addition, I authorize HRTRC to release my/my child/my ward’s records to any individual involved in medical treatment and/or necessary transportation.LIABILITY RELEASE: Under Oregon Law, an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of participating in equine activities, pursuant to section 30.691, Oregon Revised Statutes. I would like to participate in HRTRC’s program. I acknowledge the risks and potential for risks in riding and working with horses. However, I feel that the possible benefits to myself/my child/my ward are greater than the risks assumed. Intending to be legally bound, for myself and my heirs, assigns and legal representatives, I hereby forever waive and release any and all claims, whenever arising, against Faith Run Farms, LLC (“FRF”) an Oregon limited liability company, HRTRC, and their respective directors, officers, members, employees, agents and representatives arising from, or relating in any way to my/my child’s/my ward’s participation in any HRTRC program or presence on the FRF property generally.
I accept and agree to the terms and conditions listed above. *

Agree
Photo & Publicity Release

I DO/ I DO NOT Consent to and authorize the use and reproduction by Healing Reins Therapeutic Riding Center 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 DO I DO NOT
Participant Signature OR Parent/Guardian Electronic Signature if participant is a minor or has a legal guardian *
Date Signed *

Month Day Year
Emergency Contact Information
Emergency Contact 1 *
Relationship to Participant *
Phone Number *
Emergency Contact 2
Relationship to Participant
Phone Number
Participant Consent & Release of Information

Healing Reins will fax the required Physician's Release form to the participant's primary care provider and any other forms authorized below.
I hereby authorize¬ the following persons or facilities to release healthcare information from the records of (write participant's name here): *
Medical Doctor/Clinic Name: *
PT, OT, SLP Therapist/Clinic Name:
Classroom Individual Education Plan (IEP/IFSP) School Name:
Mental Health Practitioner/Clinic Name:
Electronic Signature *
Date: *

Month Day Year
Should be Empty:

Participant Information

For minors or adults with legal guardians/caregivers:

Who can we thank for telling you about us?

Health History

If yes, please answer the following questions.

*Healing Reins automatically calls 911 in cases of seizures lasting over 2 min. or multiple seizures in a short time frame

Physical Abilities

Sensory Concerns

Cognition and Processing: check all boxes that apply

Mental Health: Please check boxes that apply

The information provided is, to my knowledge, accurate and current. I have received and read the Participant Handbook.

Participant Consent & Release Form

Photo & Publicity Release

Emergency Contact Information

Participant Consent & Release of Information