CLIENT REGISTRATION AND RELEASE FORM

Client________________________________DOB__/___/___ Height______Weight______

Address _____________________________ City______________Zip_____County______

Home Phone _________________ Cell Phone________________ Email________________

Mother’s Name ____________________________ Employer _________________________

Father’s Name _____________________________Employer __________________________

Brother’s or Sister’s ___________________________________________________________________

School or Institution presently attending ___________________________________________________

Liability Release

________________________ would like to participate in the Flint Hills Therapeutic Riding Center Program.  I/we acknowledge the risks and potential for risks of horseback riding. However, I/we feel that the possible benefit to me/our child is greater than the risk assumed.  I/we hereby, intending to be legally bound, for myself, my heirs and assigns executors or administrators, waive and release forever all claims for damages against Flint Hills Therapeutic Riding Center, its Board of Directors’, Instructors, Therapists, Volunteers and or employees for any and all injuries and or losses I/our child may sustain while participating at Flint Hills Therapeutic Riding Center.

WARNING

Under Kansas law, there is no liability for an injury to or the death of a participant in domestic animal activities, pursuant to K.S.A. 60-4001 through 60-4004. You are assuming the risk of participation in this domestic animal activity.

Date_____________________ Signature ______________________________________

                                                                   Client, Parent or Guardian

Photo Release

I/we consent to and authorize the use and reproduction by Flint Hills Therapeutic Riding Center and of any and all photographs and any other audiovisual materials taken of me for promotional material, educational activities, exhibitions or any other use for the benefit of the program.

Date: _________________ Signature _______________________________________

                                                            Client, Parent or Guardian

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

In the event emergency medical aid or treatment is required due to illness or injury during the process of receiving services, or while being on the property of Flint Hills Therapeutic Riding Center.  I authorize Flint Hills to secure and retain medical treatment and transportation, if needed.

Name___________________________________________Phone__________________

Address_______________________City_____________________Zip_____________

In an emergency,  contact:_____________________________Phone:_______________

                           Contact:______________________________Phone:_____________

Physician’s Name____________________________________________

Preferred Medical Facility____________________________________

Health Insurance Co._____________________________Policy #________________

CONSENT PLAN

This authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedure deemed “life saving” by the physician.  This provision will only be invoked if the person below is unable to be reached.

Date:_____________Consent Signature_____________________________________

                                                           Client, Volunteer, Parent or Guardian

Print Name_____________________________________Phone:_________________

NON-CONSENT PLAN

I do not give my consent for emergency medical treatment/aid in case of illness or injury during the process of receiving services on the property of Flint Hills.  In the event emergency treatment/aid is required, I want the following procedures to take place:

 Date__________Non-consent Signature ­­­______________________                                                               Client, Volunteer, Parent or Guardian

Print Name____________________________________Phone:_______________________

↔

Rider Medical History / Physician Release / Therapy Order

Name:_________________________Phone:_______________Date of Birth:_________

Address: ________________________________________________________________

Parent/Guardian(s):  _______________________________________________________

Diagnosis: ______________________________________   Date of Onset:  __________

Height: _____ Weight: _____               Date of last tetanus: _______                     

Seizure: __No __Yes  Type____________Controlled ____   Date of last seizure:  ______

Medications: _____________________________________________________________

**For Clients with Down Syndrome:

___Negative Cervical X-ray for Atlantoaxial Instability       Date:__________

___Negative for clinical symptoms of Atlantoaxial Instability

Please indicate if client has a problem and/or surgeries in any of the following areas.  If yes, please comment.

___________________________________________________________________________________

___________________________________________________________________________________

Welcome to Flint Hills Therapeutic Riding Center!  We look forward to having you participate in our riding program.  Flint Hills strives to provide equine assisted activities and therapies to all individuals who can benefit from these unique and valuable services.

Facility and Program Regulations:

Paperwork - the following forms must be completed, signed and returned: registration, liability release, and medical history with physicians statement. 

Observing Therapy Sessions - Families, siblings and friends of our riders are welcome to observe sessions as long as it is not a distraction to the riders or horses.  Parents are responsible for the supervision of their children.  Children must be with an adult at all times and be reasonably quiet.  We do ask that you remain in the designated viewing area. 

Riding Attire -We suggest wearing long pants for the comfort of the rider.  All riders must wear a closed toe shoe, no sandals or slip-ons.  We suggest wearing a hard sole shoe with a heel, but tennis shoes will be allowed.

Riding Helmets- All riders MUST wear riding helments that meet or exceed ASTM regulations.  Helmets are provided by FHTRC for class use, or you may purchase your own ASTM-SEI approved riding helmet.

Cancellations - Riding classes will be cancelled in cases where weather plays a role in the safety of our riders, volunteers, or the horses.  Some instances may be tornado warnings, high heat index, icy or snowy road conditions, flooding and extremely cold wind chills.  All factors will be considered and a determination as to the status of the classes will be made in time to notify riders.  If you have not received notification from Flint Hills and you feel there is a possible indication for canceling, please contact someone from Flint Hills before you drive out to the facilities.   If a client needs to cancel a session for any reason other than illness you MUST give 24 hours notice or you will be charged for the session.  If a client is ill, please give us as much notice as possible.

Pets - Please leave pets at home.  Due to our commitment to the safety of our riders and horses, no pets will be allowed.

Feeding the Horses- Please ask a FHTRC staff member for permission to feed a horse.  Horses can get excited at the mere sight of a carrot, therefore for safety reasons, we must be sensitive as to when , where, and how the horses may receive treats.  In addition some of our horses are on very restricted diets and can not have treats.

Restroom - A restroom is available and is wheelchair accessible.  Parents please supervise small children in the restroom.

First Aid and CPR- All instructors are certified in techniques of first aid and CPR.

If you have further questions about our program, please call the office at (316)733-8943 to set up an appointment.  Our goal is to provide a safe atmosphere that allows our riders to have fun and enjoy their time at FHTRC.