Healing with Horses Ranch Student Application · Healing with Horses Ranch will cancel classes in...

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Healing with Horses Ranch 10014 FM 973, Manor, TX 78636

(512) 228-4126 office www.healingwithhorsesranch.org

Created on 1/8/2014 by PAD

Healing with Horses Ranch

Student Application Complete Name:

Nickname: Date of Birth

Please circle below your preferred method of communication

Home phone: ( ) Cell phone: ( ) Work phone: ( )

Home email: Work email:

Mailing address:

City: State: Zip Code:

Gender: ____M ____F Height: __________(inches) Weight: _________(lbs)

Race: ______________ Language Spoken at home: ___________________ Language understood: _____________________

If Under 18 Years of Age or Legal Guardian Parent/Legal Guardian Name:


Care Giver information Care Giver’s Name (if applicable):


Emergency Contact Information

Name: Relationship:


Name: Relationship:


Health History

Physician’s Name:

Health Insurance Company:

Health Insurance Policy Number:

Allergies to medications or environment:

Current medications:

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Printed Name: Date:

Photo Release o I Consent o I do NOT Consent

Consent to and authorize the use and reproduction by Healing with Horses Ranch 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 or PATH, Intl..

Signature of client, parent or guardian

Statement of Confidentiality I understand that all information, both written and verbal, regarding clients at Healing with Horses Ranch, and confidential business matters shall be held in strict confidence at all times except as needed with the facility for therapy and/or business purposes. I understand that a breach of confidentiality is grounds for dismissal and may also result in legal prosecution.


Liability Release I, ________________________ , the undersigned parent or guardian of _________________________, a

minor, would like my child or ward to participate at Healing with Horses Ranch.

I acknowledge the risks and potential for risks of horseback riding. I understand that I/my son/daughter/

ward, will be working with and around horses, as well as, riding the horses of Healing with Horses Ranch.

However, I feel that the possible benefits to myself/son/daughter/ward are greater than the risk as-

sumed. I, the undersigned student and/or parent or guardian, hereby, intending to be legally bound, for

myself, my heirs and assigns, executors or administrator, waive and forever release, acquit, discharge and

hold harmless all claims for damages against Healing with Horses Ranch , its board of directors, trustees,

agents, instructors, therapists, employees, representatives, volunteers, owners of property on which

Healing with Horses Ranch operates, successors or assigns on account of any personal injuries and/or

personal damages known or unknown, or in any way growing out of, the acts of Healing with Horses

Ranch , its board of directors, trustees, agents, instructors, therapists, employees, representatives, vol-

unteers, owners of the property on which Healing with Horses Ranch operates, successors or assigns.

WARNING UNDER TEXAS LAW (CHAPTER 87, CIVIL PRACTICE AND REMEDIES CODE), A FARM ANIMAL PROFES-SIONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN FARM ANIMAL ACTIVI-TIES RESULTING FROM THE INHERENT RISKS OF FARM ANIMAL ACTIVITIES.


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Healing with Horses Ranch Rules and Regulations

Initial

and date

I understand and agree to abide by the following policies and procedures:

Age and Weight Requirements

Individuals must be at least 2 years old before they may participate in the Healing with Horses Ranch Therapeutic Riding Program.

Rider + tack may not exceed 20% of our horse’s weight. (Example: A rider that weighs 180 lbs using a saddle that weighs 20 lbs must ride on a horse that weighs greater than 1000 lbs.)

Safety requirements Individuals may not be allowed to participate in the program if any of the following situations occur

Participant’s physical condition is in any way exacerbated by riding

An appropriate horse is no longer available for the participant

The participant’s behavior poses safety concerns for the participant, staff, volunteer or horse (at the discretion

of the instructor)

Payment Policy Payment must be received each session PRIOR to services being rendered.

Cancellation Policy and Make up Lesson Policy

In order to maximize our rider’s progress, it is critical that you attend all therapy sessions. Arriving late or missing appointments impairs our rider’s ability to progress, disrupts staff schedules, limits other riders’ abilities to get ap-pointments and may affect your agency coverage.

If you must cancel an appointment, please call the office at 512-228-4126 - 24 hours or more in advance.

All cancellations made less than 24 hours prior to an appointment will be considered a “No Show” and will re-

sult in a $25 cancellation fee due before the rider’s next visit.

Fees may be waived with a Doctor’s written excuse.

3 cancellations in a row OR 5 cancellations per fiscal year could result in the loss of your scheduled appoint-

ment time and/or scholarship.

Agency-pay riders should assume that the agencies will not pay these charges so families should be prepared

to pay out of pocket.

Weather Policy

Therapeutic riding sessions may include occasional ground lessons (i.e. not riding a horse) targeting specific

goals and objectives. These will be administered if temperature + humidity are defined as unsafe by the

national weather Bureau or if temperature drops below 25 degrees Fahrenheit.

Healing with Horses Ranch will cancel classes in the event of a Manor ISD school cancellation or if there is a

national weather service warning for Travis County. Every attempt to schedule make-up classes will be

made for Healing with Horses Ranch cancellations.

I have read and understand what is written and agree to follow the policies and procedures set forth by Healing with Horses Ranch.

Signature of Client

Printed name of Client

Date:

Signature of Clients’ parent or guardian:

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Healing with Horses Ranch Rider RULES and REGULATIONS

A parent or designated adult must be on the premises at all times during the time a student is on Heal-ing As of September, 1995, Texas enacted the following Law:

WARNING

UNDER TEXAS LAW (CHAPTER 87, CIVIL PRACTICE AND REMEDIES CODE), A FARM ANIMAL PROFES-SIONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN FARM ANIMAL ACTIVI-

Only staff, volunteers and students with supervision will be allowed beyond designated visitor areas. Off limit areas include, but are not limited to, the horse tacking area, mounting ramp, horses paddocks, tack room, and arena. For the safety of everyone, Healing with Horses Ranch staff and volunteers will strictly enforce this rule.

Permission must be obtained from the student, parent, instructor and volunteers before photos are taken or videos taped.

Unsupervised children are not allowed at Healing with Horses Ranch. Siblings of students must be su-pervised at all times while on Healing with Horses Ranch premises. Siblings will NOT be allowed in “authorized personnel only” areas including stalls unless supervised by an instructor.

Please do not run while on property (unless in an emergency).

Students should be punctual for classes. This will allow everyone the opportunity to ride for his/her allotted time. Classes will end punctually.

All students are required to wear an ASTM-SEI approved riding helmet during all equine activities un-less an Alternative Helmet Waiver has been filed in the participant’s file. Approved helmets are availa-ble at Healing with Horses Ranch for students’ use.

Students should dress appropriately for horse related activities. This includes but is not limited to com-fortable, closed toe, safe shoes, weather appropriate attire, sunscreen, etc.

Never hand feed treats to horses.

Healing with Horses Ranch is private property. There is no admittance outside of operating hours un-less prior authorization from the Executive Director has been obtained.

NO SMOKING ON THE PREMISES.

I have read and understand what is written and agree to follow the rules and regulations set forth by Healing with Horses Ranch. I understand and am aware of the Texas Farm Animal Liability Act (item 3 above).

Signature of Client

Printed name of Client

Date:

Signature of Client’ parent or guardian if Client is under the age of 18:

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Participant Health History and Goals

Participant Name: ________________________________________________________

Participant Diagnosis: ______

Describe participant’s abilities/difficulties in the following areas (include assistance required or equipment needed)

as well as your goals and objectives:

Physical

___Independent Ambulation

___Needs supervision and verbal cuing for ambulation

___Semi dependent ambulation (requires some assistance for balance only)

___Nonfunctional ambulation (requires support from more than one person)

High tone Low tone uses assistive devices: type of device________________

Improve gross and fine motor skills Improve motor planning Improve balance

Communication Verbal words phrases sentences Nonverbal Signs Gestures

uses assistive devices type_____________________________________________________

Understands most understands some Understands very little

Explain ________________________________________________________________________

Goals _________________________________________________________________________

Vision No vision issues Visual impairment uses assistive devices: type of device______

Explain ________________________________________________________________________

Auditory

No hearing issues auditory defensiveness uses assistive devices: type of device______

Explain ________________________________________________________________________

Cognitive

Age Level ________

Behavioral

Impulse control Fearful Anxious Non-compliance

Attention/focus Easily frustrate Hyperactivity

Behavior modification techniques used: ______________________________________________

Explain_________________________________________________________________________

Goals _________________________________________________________________________

Sensory Integration/Social

Likes/Strengths __________________________________________________________________________

Hobbies or preferred activities__________________________________________________

Dislikes /fears ___________________________________________________________________________

Goals_____________________________________________________________________________________

Equitation/ Horseback Riding Goals

Horse Care Showmanship/leading Riding independently English Riding

Western Riding Dressage and trail Interested in other competitions (additional fees may apply)

Goals _________________________________________________________________________

Signature and Date: __________________________________________________________________

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Date: Dear Physician: Your patient, (participant’s name) is interested in participating in supervised equestrian activities. In order to safely provide this service, our center requests that you complete/update the attached Medical History and Physician’s Statement Form. Please note that the following conditions may suggest precautions and contrain-dications to therapeutic horseback riding. Therefore, when completing this form, please note whether these condi-tions are present, and to what degree.

Thank you very much for your assistance. If you have any questions or concerns regarding this patient’s participa-tion in therapeutic equine activities, please feel free to contact the center at the address/phone indicated above.

Orthopedic Medical/Psychological

Amputation Allergies

Atlanto-axial Instability – Animal Abuse

include neurologic symptoms Physical/Sexual/Emotional Abuse

Coxa Arthrosis Blood Pressure Control

Cranial Deficits Dangerous to self or others

Heterotopic Ossification/Myositis Ossificans Exacerbations of medical conditions

Joint subluxation/dislocation Fire Settings

Osteoporosis Heart Conditions

Pathologic Fractures Hemophilia

Spinal Fusion/Fixation Medical Instability

Spinal Instability Abnormalities Migraines

Post Traumatic Stress Disorder

PVD

Neurologic Respiratory Compromise

Recent Surgeries

Hydrocephalus/Shunt Substance Abuse

Seizure Thought Control Disorders

Spina Bifida: Chiari II malformation

Tethered Cord

Hydromyelia

Weight control Disorder

Other

Age – under 4 years

Indwelling Catheters

Medications – i.e., photosensitivity

Poor Endurance

Skin Breakdown

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Participant’s Medical History & Physician’s Statement and Prescription

Participant: __________________________ DOB: ________ Height: ________ Weight: ______________

Diagnosis: ________________________________________________ Date of onset: ________________

Medications: ___________________________________________________________________________

Seizure Type: _____________________________ Controlled: Y N Date of Last Seizure:_______________

Shunt Present: Y N Date of last revision: _________________________________________________

Special Precautions/Needs:________________________________________________________________

Mobility: Independent Ambulation Y N Assisted Ambulation Y N Wheelchair Y N

For those with Down Syndrome:

Atlanto-Dens Interval x-rays date (if applicable)(Not Required): __________ Result: + -

Neurologic Annual Exam Symptoms of Atlanto-Axial Instability: _______________________________________________

Please indicate current or past difficulties in the following systems/areas, including surgeries:

Physician’s Prescription

To my knowledge, there is no reason why this person cannot participate in supervised equestrian activities. However, I understand that the therapeutic riding center will weigh the medical information above against the existing precautions and contraindications.

This is a prescription for Equine Assisted Activities and Therapies in conjunction with the Healing with Horses Ranch and a Certified PATH, Intl. instructor.

Recommended Frequency: 1X/week __________________

Precautions:

Physician’s Signature: _________________________ Date:

Physician’s Name: __________________________ Address: ____________________ __________________________________________________ Phone: ______________ Fax: ______________ E-mail: _____________________________________________________________________________________________

Yes No Comments

Auditory

Visual

Tactile Sensation

Speech

Cardiac

Circulatory

Integumentary/Skin

Immunity

Pulmonary

Neurological

Muscular

Balance

Orthopedic

Allergies

Learning Disability

Cognitive

Emotional/Psychological

Pain

Other

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Date Received__________________________

Client’s Name _____________________________________

HEALING WITH HORSES RANCH

2012 Explanation of Services

Therapeutic Riding

Scheduled on weekends and weekdays on space available basis. Private and semi-private lessons are taught by certified

PATH, INTL. therapeutic riding instructors. The emphasis is on developing riding skills to improve functional life skills.

This may include horseback riding, horsemanship and ground lessons. Safety is a priority. They are scheduled for 1 and

½ hours with riders having the opportunity to bond with and get their horse ready with “their” volunteer, riding for up to

45 minutes, and then helping to untack and put their horse up with some goals being sequencing, time management, car-

ing for others, and communication, in addition to the riding skills, balance and coordination, increasing core strength,

improving gross and fine motor skills.

Equine Facilitated Learning—Work to Ride Program Please call for additional information

The goal of the program is to teach individuals with physical, mental, or emotional disabilities job skills that will be

applicable in the real world, allowing them to get real life experience that will translate into job obtainment. Their work

on the ranch will earn them "bucks" that can be cashed in for therapeutic riding lessons.

Equine Facilitated Learning –At Risk Youth/Those that have trauma/PTSD

Please call for additional information

Equine-Facilitated Education (EFL) benefits at-risk youth, those that have experienced trauma, or those affected by PTSD

and their families by offering them a safe, accepting, non-judgmental environment where they can learn life skills such as

anger management and explore character assets such as trust, honesty and responsibility. Through guided interactions

with Healing with Horses Ranch’s horses, youth and adults develop a sense of self-worth, self-knowledge and self-

confidence. Program goals include development of coping skills, reduced truancy and improved academic performance,

healthier family relationships, job and job-search skills, and reduced or eliminated self-destructive behaviors such as

promiscuity, use of drugs, and gang associations.

Equine Facilitated Learning- Life Skills Classes

Please call for additional information

Equine-Facilitated Education (EFL) benefits youth in life skills classes by incorporating the students IEP with experien-

tial interactive learning while developing riding skills and improving functional life skills. This may include horseback

riding, horsemanship and ground lessons. Safety is a priority. Classes are scheduled for up to 2 1/2 hours depending on

the class size with riders being encouraged to help get their horse ready with “their” volunteer, riding for up to 45

minutes, and then helping to un-tack and put their horse up in addition to experiential taught class curriculum. Goals in-

clude improved academic performance, sequencing, time management, caring for others, and communication, in addition

to the riding skills, balance and coordination, increasing core strength, improving gross and fine motor skills.

Non-Refundable Application Fee - $25 New Student Screening Fee - $50

Less than 24 hours Cancellation Fee/No Show Fee - $25

Please note: There are contraindications for Equine Facilitated Activities. Healing with Horses Ranch reserves the right to refuse services if

contraindications exist which do not allow Healing with Horses Ranch to safely serve all parties involved.

Schedule Request Form

Please indicate below when you are NOT able to ride by placing an X in the boxes. Place a 1, 2, and 3 in the boxes for your 1st, 2nd, and

3rd choices. There is no guarantee that you will get your 1st, 2nd, or 3rd choices, however we will try to accommodate if possible. Students

will be scheduled in large part by their age and experience level of riding.

TIME MON TUES WED THURS FRI SAT SUN

8:30-10:00 AM

10:00-11:30 AM

12:30-2:00 PM

2:00-3:30 PM

3:30-5:00 PM

6:00-7:30 PM

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Weekly Monthly 11 week session Yearly -37 weeks

Therapeutic Riding Semi-private (up to 3)

$50 $200 $550 $1850

Therapeutic Riding

Private $60 $240 $660 $2200

EFL for At Risk Youth

Semi-private (up to 3) $80/per

person $320 $880 $2960

EFL for Life Skills class

(up to 6) $200/class $800 $8800 $7400

Work to Ride

(8 hours of mentored

work + 1.5 hr TR Class)

$160/

9.5 cycle

$640/ 4

9.5 hr cycles

Credit Card Information

Card Holders ‘s Name: (as shown on credit card)

Billing Address Zip Code:

Credit Card Type: MasterCard Visa Discover American Express

Credit Card Number: Security Code: Expiration Date: /

I authorize Healing with Horses Ranch to automatically bill the card listed above as specified:

Monthly by 11 week Session yearly (37 weeks)

Signature: Date:

*Please NOTE: All fees are due by session or month PRIOR to r iding.

Non-Refundable Application Fee - $25 New Student Screening Fee - $50

Less than 24 hours Cancellation Fee/No Show Fee - $25

I, ________________________________________ (name of student or parent/guardian) will pay for Healing with Horses

Ranch lessons via the following (check all that apply):

Private Pay

Agency Funding (Billing will be done by Healing with Horses Ranch to one of the following agencies OR agency paper -

work completed by Healing with Horses Ranch for reimbursement to student family):

Bluebonnet Trails MHMR Austin Travis County MHMR

Central Counties MHMR DSSW

Touch of Class D & S Residential

TCB / DARs Other___________________________

Payments will be accepted via cash, check, or credit card.

If you would like to enjoy the convenience of automatic billing, simply complete the Credit Card Information section below and

sign the form. All requested information is required. Upon approval, we will automatically bill your credit card for the amount

indicated and your total charges will appear on your monthly credit card statement. You may cancel this automatic billing au-

thorization at any time by contacting the Healing with Horses Ranch office.

HEALING WITH HORSES RANCH

Fees and Payment Planning Form

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Healing with Horses Ranch

2012 Scholarship Application Form

Rider fees are necessary to help defray the expense of equine assisted therapy and cover only 40% of the ac-

tual cost of each lesson. Healing with Horses Ranch’s Board of Directors believes that no rider should be

turned away due to finances. The scholarship application, as well as the Rider Application must be renewed

each fiscal year. Scholarships awarded with a start date of January 1 and will remain in effect for the entire

year. If clients receive another source of financial aid, they will be ineligible for scholarship funds.

Applications for scholarships must include:

Completed Scholarship form

The first page of the most recent IRS income tax return If the rider is a minor, the tax return for the responsible party is required.

You will be notified in writing as to the scholarship amount you have been awarded.

Rider Name:_____________________________________________________________________________

Parent/Guardian:_________________________________________________________________________

Primary phone: ____________________________ Secondary Phone: __________________________

Email Address:___________________________________________________________________________

Occupation: ______________________________ Spouse’s Occupation: ____________________________

Responsible party: ________________________________________________________________________

Address/City/Zip: ________________________________________________________________________

Annual Family income:____________________ Number in family:________________________________

Rider/parent/guardian signature: ________________________________________ Date: ______________

Office Use Only:

Date Approved: ___________________ Level: _____________________ Date Notified: ________________

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