Front Range Exceptional Equestrians
PO Box 272452
Ft. Collins, CO 80527-
(970) 221-
CLIENT APPLICATION/ HEALTH HISTORY
CLIENT’S Name ____________________________________Date of Birth _______
Height ______Weight ______Today’s Date ________________________________
Whom should we contact for scheduling classes? ___________________________
Contact Name ________________________________________________________
Contact Mailing Address________________________________________________
City, State, Zip+4 _______________________________Contact Phone ________
Parent/Guardian Address and Phone (if minor)_______________________________
E-
School or Group Home placement Physician Name/Phone
Please list type of therapy the client is currently receiving with Therapist Name/Phone:
How did you hear about our program?_________________________________________
Are you a returning rider that has participated in our program previously? ___________
Diagnosis___________________________ Current Medications: ___________________
To help us place the client in an appropriate class, and work effectively with
him/her, please check any of the following that describes the client:
Communication Ability: ____Uses language normally ____Uses Sign Language/finger spelling
____Understands spoken language ____Uses nonverbal communication ___Hearing Impaired
____Client’s speech is difficult to understand _____Responds slowly to verbal communication
____Client’s speech is usually understood ____Does not respond to verbal communication
Communication aids used by client are:________________________________________
Physical Skills: ____Sits independently ____Uses hands well ____Transfers independently
____Walks independently ____Uses hands fairly well ___Stands with help
____Stronger Left/ Right side ____Does not use hands ____Cannot stand/ walk
Mobility aids used by client are:______________________________________________
Social Skills: Does client typically cope well with new people and new situations? YES NO
Has the client ever participated in therapeutic riding classes before?
If so, where?_____________________________________________________________
Does the client exhibit any behaviors which may affect his/her ability to benefit from our program or to work with an Instructor or volunteers in a group setting? Please explain. _______________________________________________________________________
Does the client have any fears we should know about (animals, heights, falling)? _______________________________________________________________________
Health History: Please indicate if the client has any current or past problems in the following areas.
Please explain any Yes answers.
Health Area Yes NO Comments
Heart/Circulation
Breathing
Asthma
Chronic Pain
Skin Ulcers
Vision
Bone/Joint
Allergies
Behavior
To the best of my knowledge, I confirm that the information I have provided is true
and correct at this time.
________________________________________ Date______________________
Client, Parent, or Legal Guardian
PHOTO RELEASE
I DO/ DO NOT (circle one) consent to and authorize the use and reproduction by Front Range Exceptional Equestrians of any and all photographs and other audiovisual materials taken of me/ my child/ my ward for promotional printed material, educational activities, exhibitions, or for any other use for the benefit of the Front Range Exceptional Equestrians program.
_____________________________________ Date____________________________
Client, Parent, or Legal Guardian
Everyone must complete and sign these releases before participating in our program. If you are under 18 a parent or guardian must sign.
EMERGENCY TREATMENT RELEASE
Rider Name_________________________ Parent/Guardian Name (if minor) ______________________________________________________________________
Address_______________________________________________________________
Phone (Day)________________________ Evening_____________________________
Whom shall we call in case of emergency during time at Front Range Exceptional Equestrians:
Name______________________________ Phone______________________________
Doctor’s Name_______________________ Phone______________________________
Please list any health condition which may affect your safety and that emergency personnel should be aware of (i.e. allergy, asthma, diabetes, seizures, hearing impairment, etc.)
Please list any special medical problems in case of emergency i.e. allergy to medication, bee sting, etc)
Consent for Medical Treatment
I give my consent for emergency medical treatment/aid in the case of illness or injury
during my/my child’s participation in the Front Range Exceptional Equestrians program
or while being on the property of the agency. This authorization includes x-
Consent signature ______________________________________________Date____________________
Non-
I DO NOT give my consent for emergency medical treatment in the case of illness or injury while participating in the Front Range Exceptional Equestrians program or while being on the property of the agency. If emergency treatment/aid is required, the following should occur: _________________________________________________________________
FOR ALL PARTICIPANTS UNDER 18 A PARENT or GUARDIAN WILL BE PRESENT ON SITE AT ALL TIMES.
Non-
_____________________________________________ Date____________________
LIABILITY RELEASE
WARNING: Under Colorado law, an equine professional is not liable for an injury to
or death of a participant in equine activities resulting from the inherent risks
of equine activities, pursuant to Section 13-
_______________________(Name) requests participation in the Front Range Exceptional Equestrians therapeutic riding program. I acknowledge the risks and potential risks of injury during horseback riding therapy and working with horses. However, I feel that the possible benefit to myself/ my child/ my ward warrants assumption of these risks. I hereby, intending to be legally bound, for myself, my heirs, and my assigns, executors and administrators, waive and release forever all claims for damages against Front
Range Exceptional Equestrians, its Board of Directors, Instructors, Therapists, Aides, Volunteers, Horse Owners, Property Owners, and/or Employees for any and all injuries and/or losses that I/ my child/ my ward may sustain while participating in Front Range Exceptional Equestrians therapeutic riding program.
__________________________________________
Signature of person releasing liability Date
__________________________________________
Print Name Relationship to client
REMEMBER : HAVE YOU COMPLETED THE FOLLOWING (circle yes or no)?
Rider’s Medical History/ Physician’s Consent (form is signed by Physician) YES NO
Client Application/Health History (form is signed and dated) YES NO
Emergency Treatment Release (form is signed and dated) YES NO
Liability Release (form is signed and dated) YES NO
Photo Release (form is signed and dated YES NO
Areas of Learning/ Goal Sheet YES NO
Class Preference Form YES NO
WHEN ALL FORMS ARE SIGNED AND COMPLETED PLEASE RETURN TO:
Front Range Exceptional Equestrians
PO BOX 272452
Fort Collins, CO 80527-
YOU WILL BE NOTIFIED WHEN YOU ARE PLACED IN A CLASS .
THANK YOU
