Download Report

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Participant!s Application & Health History!
GENERAL INFORMATION
Participant:
DOB:
Age:
Height:
Weight:
Gender: M F
Address:
Phone:
Email:
Alternative #: __________________
Employer/School:
Address:
Phone:
Parent/Legal Guardian:
Caregivers:
Address (if different from above):
Phone:
Referral Source:
Phone:
How did you hear about the program?
HEALTH HISTORY
Diagnosis:
Date of Onset: _________________
Please indicate current or past special needs in the following areas:
Y
N
Comments
Vision
Hearing
Sensation
Communication
Heart
Breathing
Digestion
Elimination
Circulation
Emotional/Mental Health
1 Behavioral
Pain
Bone/Joint
Muscular
Thinking/Cognition
Allergies
MEDICATIONS (include prescription and over-the-counter; name, dose and frequency)
Describe your abilities/difficulties in the following areas (include assistance required or equipment
needed):
PHYSICAL FUNCTION (e.g., mobility skills such as transfers, walking, wheelchair use, driving/bus
riding)
PSYCHO/SOCIAL FUNCTION (e.g.,. work/school including grade completed, leisure interests,
relationships-family structure, support systems, companion animals, fears/concerns, etc.)
GOALS (i.e. why are you applying for participation? What would you like to accomplish?
Signature:
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Date:
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Authorization for Emergency Medical Treatment Form
Participant __!!!Volunteer___
Name: _________________________________________ DOB: _______________ Phone: ______________
Address: _________________________________________________________________________________
Physician’s Name: ____________________________________ Preferred Medical Facility: _______________
Health Insurance Company: _____________________________ Policy #: _____________________________
Allergies to medications:_____________________________________________________________________
Current medications: ________________________________________________________________________
In the event of an emergency, contact:
Name: _________________________________________ Relation: _____________ Phone: ___________________
Name: _________________________________________ Relation: _____________ Phone: ___________________
Name: _________________________________________ Relation: _____________ Phone: ___________________
In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services,
or while being on the property of the agency, I authorize Blue Sky Therapeutic Riding & Respite to:
1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to the authorized individual or agency involved in the medical
Emergency treatment.
3. Blue Sky's insurance is secondary to any individual’s primary insurance.
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(s) above is unable to be reached.
Date: ____________ Consent Signature: ___________________________________________________________
Client, Parent or Legal Guardian
Non-Consent Plan
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of
receiving services or while being on the property of the agency.
____ Parent or legal guardian will remain on site at all times during equine assisted activities
____ In the event emergency treatment/aid is required, I wish the following procedure to take place:
Date: ___________ Consent Signature: ___________________________________________________________
Client, Parent or Legal Guardian
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3 RELEASE OF LIABILITY
Name of Rider ____________________________________________________________
Blue Sky Therapeutic Riding & Respite, its officers, members, employees, contractors, property
Owners and agents will not be responsible for any damages to person, animal or property at the Blue
Sky leased facility or its grounds, nor will they be responsible for any property lost or destroyed. The
undersigned rider/parent/guardian/ volunteer hereby releases Blue Sky, its officers, members,
employees, contractors, property owners and agents from any and all liability, claims and damages
whatsoever(including costs, expenses, and attorney’s fees) that might result from damages, injuries,
or losses to their person or property during, or in connection with, or arising out of any show, clinic,
event or function, whether or not such damages, injuries, or losses result directly or indirectly from
the negligent act or omission of such released parties.
WARNING: UNDER TEXAS LAW (CHAPTER 87, CIVIL PRACTICE AND REMEDIES
CODE), 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 EQUINE ACTIVITIES.
In exchange for the use of property leased by Blue Sky and other valuable consideration, I agree that
my use of the premises and any animals, facilities, or equipment leased or owned by Blue Sky is at
my own risk. I further agree to indemnify and hold harmless Blue Sky, their respective officers,
members, employees, contractors, property owners and agents from any and all suits, actions, or
claims of any type arising from my use of the premises or participation in the equine activity of such
use by my guest, whether or not such claims result directly or indirectly from the negligent act or
omissions of the indemnified parties or otherwise.
I acknowledge that riding and involvement with horses is a high-risk activity. I have read this
agreement and fully understand its content.
PLEASE SIGN HERE: _______________________________________
(Adult rider or parent / guardian of minor rider/volunteer)
_______________________________________
Date
Riders cannot participate in any activity at Blue Sky without this signed form.
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PHOTO RELEASE
I ! DO
"! DO NOT
Consent ____________________________________to and authorize the use and reproduction by (Blue
Sky Therapeutic Riding and Respite) 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.
Signature: ________________________________________________ Date: ________________________
Client, Parent or Legal Guardian
Confidentiality Agreement
I understand that all information (written and verbal) about participants at this PATH Intl. center is confidential and will not
be shared with anyone without the expressed written consent of the participant and his/her parent/guardian in the case of a
minor.
Signature:
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(volunteer/staff/ parent/ guardian)!
Date:
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Dear Health Care Provider:
Your patient
(Participant’s name)
is interested in participating in supervised equine 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 contraindications to equine
activities. Therefore, when completing this form, please note whether these conditions are present, and to
what degree.
Orthopedic
Medical/Psychological
Atlantoaxial Instability - include neurologic symptoms
Coxarthrosis
Cranial Defects
Heterotopic Ossification/Myositis Ossificans
Joint subluxation/dislocation
Osteoporosis
Pathologic Fractures
RA, MS)
Spinal Joint Fusion/Fixation
Spinal Joint Instability/Abnormalities
Allergies
Animal Abuse
Cardiac Condition
Physical/Sexual/Emotional Abuse
Blood Pressure Control
Dangerous to Self or Others
Exacerbations of Medical Conditions (e.g.,
Neurologic
Migraines
PVD
Respiratory Compromise
Recent Surgeries
Substance Abuse
Hydrocephalus/Shunt
Seizure
Spina Bifida/Chiari II Malformation/Tethered Coed/Hydromyelia
Other
Age - under 4 years
Indwelling Catheters/Medical Equipment
Medications - e.g., Photosensitivity
Poor Endurance
Skin Breakdown
Fire Settings
Hemophilia
Medical Instability
Thought Control Disorders
Weight Control Disorder
Thank you very much for your assistance. If you have any questions or concerns regarding this patient’s
participation in equine-assisted activities, please feel free to contact the center at the address/phone
indicated above.
Sincerely,
Blue Sky Therapeutic Riding & Respite Board of Directors
7 Participant!s Medical History & Physician!s Statement
Participant:
Address:
Diagnosis:
Past/Prospective Surgeries:
Medications:
Seizure Type:
Shunt Present: Y N Date of last revision:
Special Precautions/Needs:
DOB:
Height:
Weight:
Date of Onset:
Controlled: Y N Date of Last Seizure:
Mobility: Independent Ambulation Y N Assisted Ambulation Y N Wheelchair: Y N
Braces/Assistive Devices:
For those with Down Syndrome: Neurologic Symptoms of Atlantoaxial Instability:
Present
Absent
Please indicate current or past special needs in the following systems/areas, including surgeries. These conditions may
suggest precautions and contraindications to equine activities.
Y
N
Comments
Auditory
Visual
Tactile Sensation
Speech
Cardiac
Circulatory
Integumentary/Skin
Immunity
Pulmonary
Neurologic
Muscular
Orthopedic
Allergies
Learning Disability
Cognitive
Emotional/Psychological
Pain
Other
Given the above diagnosis and medical information, this person is not medically precluded from participation
in equine-assisted activities and/or therapies. I understand that the PATH Intl. Center will weigh the medical
Information given against the existing precautions and contraindications. Therefore, I refer this person to the
PATH Intl. Center for ongoing evaluation to determine eligibility for participation.
Name/Title:
MD DO NP PA Other
Signature:
Date:
Address:
Phone: (
)
License/UPIN Number:
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