2023 Participant 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 on 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.
Healing Reins' Services
Note: If you are not sure which service you would like to enroll in, please contact Candace Martin, Operations Coordinator at: (541) 382-9410 or candacem@healingreins.org
- Adaptive Horsemanship: includes groundwork and riding for participants of all ages, abilities, and experience levels
- REACH: After school and summer workshops for students ages 9-18. Includes groundwork and classroom experiences
- Heroes Horsemanship: Groundwork and riding tailored for Veterans and First Responders, and their families
Which Healing Reins Service is the participant enrolling in?*

Adaptive HorsemanshipREACHHeroes Horsemanship
Again, if you are not sure which service you would like to enroll in, please contact Candace Martin, Operations Coordinator at: (541) 382-9410 or candacem@healingreins.org
If you are enrolling with a group, please provide the group code here:
Name of Person Completing This Form*

First NameLast Name
Email Address*
How Do You Prefer To Be Contacted?*

EmailTextPhone
Preferred Number for Phone Calls*
Preferred Number for Texts*
Note: Your service provider may charge you fees for receiving text messages from Healing Reins.
Preferred Email Address (if different from above)
Were you referred to Healing Reins by a person, organization or agency?

YesNo
Name of Person, Agency, or Organization that referred you to Healing Reins (so we can thank them!)
Person Completing This Form is the:

ParticipantParticipant's ParentParticipant's Legal Guardian
Participant's Name*

First NameLast Name
Is the Participant a:*

MinorAdult with Legal Guardian or CaregiverIndependent Adult
Parent, Guardian, or Caregiver Name
Phone Number

Area CodePhone Number
Employer
Email Address
Other Parent, Guardian, or Caregiver Name
Phone
Employer
Email
Please provide names and phone numbers of any additional caregivers who may transport or be responsible for the participant
Participant's Date of Birth*

MonthDayYear
Participant's Age*
Participant's Street Address*
Participant's City*
Participant's Zip Code*
Participant's School/Institution/Employer Name*
Does the participant have an IEP, IFSP or 504 plan on file with their school (if applicable)?*

Yes - IEPYes - IFSPYes - 504No / Not Applicable
Are there any accommodations from the IEP or 504 plan, or in general, that would be helpful for Healing Reins' instructors to know or use?*
Participant's Gender Identity (check all that apply and/or use the "Other" field):*

FemaleMaleNonbinary
Please share the participant's pronouns:

she/her/hershe/him/histhey/them/theirs
What is the Participant's racial/ethnic background? (check all that apply)*

Prefer Not To SayAsianBlack/African AmericanCaucasian/WhiteHispanic or Latino/a/xMiddle EasternNative American/Alaskan NativePacific Islander
Other Demographic Data: Please select any / all that apply to the participant or their household*

Living on Low IncomeQualifies for / Receives SNAP (Supplemental Nutrition Assistance Program) benefitsQualifies for free or reduced school meals (breakfast, lunch, diiner)Currently Part of the Foster Care System: Child or Youth in Foster Care, or part of household that includes foster youth or childrenExperienced or Experiencing Childhood Trauma: foster care placement, incarcerated parents, juvenile justice system, homelessnessCurrently experiencing homelessnessLesbian, Gay, Bisexual, or QueerTransgender/Nonbinary/Gender NoncomformingImmigrant or RefugeeExperiencing a DisabilitySpeaks a language other than English at homeActive Duty MilitaryFirst Responder**Veteran: Served before 9-11-2001Veteran: Post 9-11-2001None of the AbovePrefer Not To Say
**Note: Healing Reins defines "First Responder" as: law enforcement officers, paramedics, EMT's, firefighters, and nurses, doctors and other medical personnel who are also required to respond directly to disasters and critical situations.
Please describe the participant's experience with horses:

NoneIndividual or One-Time Trail Rides, Sleigh Rides, Pony RidesSummer Camps with HorsemanshipSome Riding Lessons / Beginner RiderIntermediate RiderAdvanced / Experienced Rider
Participant's Height*
Participant's Weight*
Is the participant taking any prescription medicine, or over the counter medications, that might affect their mood, concentration, or interaction with horses and other participants? If yes, please list and describe.*
Does the participant experience any sensory processing sensitivity, disorders, or disabilities, in the following areas:

Visual (seeing)Auditory (hearing)Olfactory (smelling)Tactile (touch)
Please provide any details regarding the participant's sensory processing sensitivity, disorders, or disabilities
Goals: We will talk about your goals for participating at Healing Reins during your orientation. Is there anything about your goals that you would like us to know now?*
Behavioral Health Issues. Does the participant have a history of, or are they currently experiencing, any of the following:*

Hyperactivity, Compulsive Behavior or rituals, unable to relaxAttention or memory issuesAggression, Violence, Destruction of Property / Fire Starting, or making threats of any of theseAbuse of Animals, or making threatsSuicide Ideation or Self-HarmSexual Disorders or Behavior: Addiction to pornography, preoccupation with sex, sexual dysfunction, decreased or lack of sexual interest, promiscuity, infidelitySubstance Use Disorder (Alcohol or other substances)Eating Disorders: purging, weight loss or gain, loss of appetite, overeating, calorie restrictingSelf-destruction/Sabotaging behaviors including lying, stealing, manipulation of others, irresponsibility, argumentative, judgement problems, stealing / shoplifting, letting others take advantage of youIsolation, Self-Neglect, withdrawal from others, loss of interest in favorite activities and previous interests, difficulty performing (or interest in) household choresGambling Addiction, Financial Problems, Legal ProblemsScreen time addictionSleep disorders, difficulty sleeping, bed wettingAbsenteeism at work or school, chronic tardinessDifficulty with co-workers, peers, supervisors, teachersPerformance issues at work or school: under performing, procrastination, or avoidance or over achieving / perfectionismNone of the above
Thoughts / Feelings / Mood. Does the participant have a history of, or are they currently experiencing, any of the following:

Anger, Hostility, Disliking Others, thoughts of harming othersAnxiety, Excessive Worry, Fear, Negative thoughts, Panic attacks, StressGrieving (death, divorce, other loss)Depression, Emptiness, Failure, Guilt, Sadness, FatigueHearing or seeing things other people do notOversensitivity to criticism or rejection, perfectionismShynessSelf Esteem: too high or too lowSpiritual, religious or moral issuesSudden mood changes or temper problemsSuspiciousness, paranoia
Family & Relationships. Does the participant have a history of, or are they currently experiencing, any of the following:

Divorce of ParentsDivorce from their own partnerLack of FriendshipsInterpersonal conflictsDifficulty with parenting / problems with childrenDifficulty with parentsProblems with spouse/partnerSeparation
Trauma. Does the participant have a history of, or are they currently experiencing, any of the following:

Emotional, verbal, physical, financial, or sexual abuse or neglect by anotherEmotional, verbal, physical, financial, or sexual abuse or neglect of anotherChildhood trauma: incarceration (juvenile justice system), foster care, parental incarceration
First Aid & Emergency Contact Information
Does participant carry an EpiPen?*

YesNo
Does participant use an inhaler?*

YesNo
Any additional allergy or first aid information you would like us to know about
Does participant have a history of seizures?*

YesNo
Please note: Healing Reins automatically calls 911 in cases of seizures lasting over 2 min. or multiple seizures in a short time frame
Type of seizure
Date of last seizure

MonthDayYear
Frequency of seizures
Duration of seizures
Indicators of oncoming seizure
Triggers
Typical recovery time
Emergency Contact 1*
Relationship to Participant*
Phone Number*
Emergency Contact 2
Relationship to Participant
Phone Number
Health & Cognitive Information
Diagnosis: Primary*
Diagnosis: Secondary
Assistive Devices. Please list and describe any assistive devices that the participant utilizes at home, work or school (include hearing, communication and visual):
Is the participant proficient in the following areas? Please check all that apply: *

Sits without assistanceStands without assistanceClimbs without assistanceHolds objectsWalks without assistanceRuns without assistance
Educational/Cognitive

Knows numbersKnows lettersKnows left/rightKnows prepositionsCommunicates feelingsMakes choices
Social

Recognizes nameMakes eye contactWaves/says hello/byeShares toys/itemsKnows safety awarenessInteracts with peersAppropriate conversationTakes turns
Language

Makes soundsSays wordsCombines 2 or more wordsSpeaks in complete sentencesUnderstands “No”Letter sound identificationSigns or uses gesturesUses picture symbols
Follows simple directions

1 Step2 Step3 StepComplex
Attention to task

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

PoorFairAverage
Problem solving

PoorFairAverage
Learning Style

Visual - learns by watchingAuditory – learns by hearingKinesthetic – learns by doing
Anything else we should know regarding the participant's health history, cognitive issues, or learning style ?
Release of Information Consent

Healing Reins will fax the required Physician's Release form to the participant's primary care provider and any other service providers authorized below.
Release of Information Authorization*

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:
Signature for Release of Information

Clear
Date of Authorization:
Photo & Publicity Release

Do you consent to and authorize the use and reproduction by Healing Reins of any and all photographs and any other audio/visual materials for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
Photo & Publicity Release*

YES, I DO 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 the participant for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.NO, 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 the participant for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
Heroes' Family Members

If you would like to participate in Heroes' Family events, please share your family members' names, ages, and relationship to you.
Agreement, Consent & Release
- The information provided is, to my knowledge, accurate and current.
- 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 (“Healing Reins”), an Oregon non-profit corporation, I authorize Healing Reins 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 Healing Reins 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, Healing Reins, 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 Healing Reins program or presence on the FRF property generally.
Agreement & Acceptance

I accept and agree to the terms and conditions listed above.
Signature

Clear
Should be Empty:

Participant Information

Healing Reins' Services

First Aid & Emergency Contact Information

Health & Cognitive Information

Release of Information Consent

Photo & Publicity Release

Heroes' Family Members

Agreement, Consent & Release