Application and Photo Release

Name: ____________________________________________________

DOB: ___ / ___ /___ Age: _____ Height: _____ Weight: _____ Male / Female

Ethnicity______________

Address: _________________________________________________County________

Home Phone: _____________________ Cell phone: __________________________

Preferred phone:_____________________________________

Email Address: _________________________________________________________
Employer/School: ________________________________________________________________
Address: _____________________________________ Phone: ________________
Parent/Legal Guardian: _________________________ Phone: _________________
Address (if different from above): ________________________________________________________________

Referral Source:
How did you hear about the program? Client Service Provider ____ Website _____
Social Media ___ Event On Site _____ Event Off Site _____ Friend _____

What medications are you currently taking, including over-the-counter medications? _________________________________________________________________
List Allergies; ________________________________________________________

Describe your abilities/difficulties in the following areas (include assistance required or equipment needed):
Experience with horses___________________________________________
___________________________________________________________
Experience with special needs_________________________________________
_________________________________________________________________
Goals: _______________________________________________________

Why are you applying for participation?
Therapeutic Riding _____ Extended Hours _______ Ranch Experience _______
Recreational Riding _____ Volunteering _________

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

Prospect Riding Center Client Eligibility Guidelines

Prospect Riding Center will make every effort to meet the needs of all clients who apply – whether for therapeutic or recreational riding. However, the nature of these activities includes limitations, precautions and occasionally contraindications.

These are due to a variety of causes, most notably the following:

• Size and weight-carrying ability of the available horses
• Nature of a disability or condition that would make it unsafe for an individual to ride
• Lack of an appropriate group for an individual to join
• Inability to schedule riding time to coincide with an individual’s school or work schedule
• Lack of an adequate number of volunteer aides for a specific time slot

The safety of student, volunteers, staff and horses are of the utmost importance and each will be taken into consideration when accepting new students. All students and their parents/guardians/caregivers must be willing to abide by all rules established and posted. Riders must be able to wear an approved riding helmet, close toed shoes.

Medical Precautions and Contraindications information is available for review from our office or you may call us to discuss.

Physicians Statement

All Prospect Riding Center Clients seeking therapeutic riding must have a signed and dated statement from their doctor, and complete all liability/information forms.

Age

Therapeutic riding clients must be at least 5 years of age.

Weight Limit

Prospect Riding Center reserves the right to impose a weight limit in the event that no horse is available to safely carry a client weighing over 180 pounds. A lower limit may be imposed if illness or injury prevents the use of a suitable horse. This rule is needed in order to protect the health and soundness of the horses as well as the safety of the rider, volunteers and staff.

Behavior

Inappropriate, unsafe or disruptive behavior or any condition where the client is harmful to him/herself or others is a contraindication to therapeutic horseback riding.

Evaluation/Re-evaluation

Each potential therapeutic/recreational client will receive an initial evaluation by a PATH-certified instructor. Based on this evaluation and the client’s medical reports, the client will be advised if therapeutic riding is recommended. All students must have signed release of liability/information forms completed.

Under certain conditions a client’s condition may change and a re-evaluation becomes necessary. Based on this re-evaluation, the client may have to cease riding/therapy. A doctor’s written verification is required for the client to resume riding.

Recognizing that horse-related activities do hold inherent risks, we need to assess student participation with a “Risk/Benefit” analysis. The essential question for all students is, “Will the benefit of equine activities outweigh the risk?” If the movement activity will cause a decrease in the student’s function, an increase in pain, or generally aggravate the medical condition, these may not be the activity of choice.

Instruction

All clients and their families need to understand that Prospect Riding Center may be at any time a teaching facility for instructors in training. As such, no guarantee is made that all lessons will be conducted by a certified instructor. However, all mounted activities are under the direct supervision of a certified instructor, who will be present in the ring at all times to observe riding session, mounting and dismounting.

Thank you for understanding these guidelines. It is the intent of Prospect Riding Center to provide the safest possible therapeutic/recreational riding lessons for our clients.

Dear Participant, Parent, or Guardian;

Thank you for your interest in Prospect Riding Center. We are dedicated to providing a quality educational and recreational therapeutic horseback riding and equine activity program for individuals with special needs, and those seeking recreational riding and equine activities.

We have established Participant Eligibility Requirements to ensure that we are providing a safe program for all of our students. Please review these requirements carefully before completing the enclosed application.

Once the entire application package has been completed, please return it to
Prospect Riding Center or mail to:

Prospect Riding Center

-or-

PO Box 424

For therapeutic riding, the Participant’s Medical History & Physician’s Statement must be completed and signed by a physician before participation can begin. After we have received and reviewed the application, we will call you when we are ready to schedule an initial evaluation lesson. There is a onetime evaluation fee of $35.

Thank you again for your interest in Prospect Riding Center and we look forward to meeting you soon! Please do not hesitate to call me if you have any questions or concerns at (941) 713-1736.

Sincerely,

Susan Tambone
PATH International Certified Riding Instructor,
Certified Driving Instructor,
Equine Specialist in Mental Health and Learning