Participant’s Application and Health History

Participant’s Application and Health History

Participant’s Name: ____________________________________________
DOB: ___ / ___ /___ Age: _____ Height: _____ Weight: _____ Male / Female
Address: ________________________________________________________________
Phone: __________ Alternate Number: __________ E-Mail Address: ________________________
Employer/School: ________________________________________________________________
Address: _____________________________________Phone: ________________
Parent/Legal Guardian: _________________________ Phone: _________________
Address (if different from above): ________________________________________________________________
Care Giver: _________________________________Phone: _________________

Referral Source: ________________________________________________________________
How did you hear about the program? ________________________________________________________________
What medications are you currently taking, including over-the-counter medications? ________________________________________________________________
________________________________________________________________
Describe your abilities/difficulties in the following areas (include assistance required or equipment needed):

Function: (i.e., mobility skills such as transfers, walking, wheelchair use) ________________________________________________________________
________________________________________________________________
Social: (i.e., work/school included grade completed, leisure interests, relationships, family
Structure, support system, companion animals, fears/concerns, etc.) ________________________________________________________________
________________________________________________________________
________________________________________________________________
Goals: (i.e. Why are you applying for participation? What would you like to accomplish?)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Photo Release
I _____ Do I _____ Do Not
Consent to and authorize the use and reproduction by Prospect Riding Center 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: _________
Parent / Legal Guardian/Participant if over 18