First Name

Last Name

Date of Birth

Address 1

Address 2

City

State
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

County

Home Phone

Cell Phone

Work Phone

Ext.

Email

Participant’s Ethnicity

Gender

Weight

Height

Primary Disability

Other Disabilities

Adaptations

Is the Participant a U.S. Military Veteran?
YesNo

If you answered Yes to the question above, which branch did you serve?

What are your dates of service?

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Participant Parent/Guardian Information (If Applicable)

If you are under the age of 18 years old, your parent/guardian must complete the following:

First Name:

Last Name

Parent/Guardian’s Cell Phone

Parent/Guardian’s Work Phone

Parent/Guardian’s Place of Employment

City

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Medicaid Information

Does the Participant qualify for Medicaid funding or long term support?
YesNo

If you answered Yes to the question above, check which program applies to the participant, and write the name of his/or county and case manager:

Children’s Long Term Support Waiver (CLTS)

County

Case Manager

Community Care Options Program (CCOP)

County

Case Manager

Comprehensive Community Services (CCS)

County

Service Facilitator

Other

County

Case Manager

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Horse/Physical Background

Has the participant ever ridden a horse?
YesNo

List of activities, sports, games, and/or reinforcements that the participant enjoys:

List of activities, sports, games, objects etc. that the participant dislikes/fears:

Physical Abilities (Mobility, transfer skills, walking):

Psychological/Social Abilities:

What benefits would you like to obtain through HGR’s programs & services? List goals here:

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Photo Release

Do you consent to and authorize the use and reproduction by Heaven’s Gait 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 organization?
YesNo

Consent Signature

Date

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Liability Release

(Participant’s Name) would like to participate in equine assisted services at Heaven’s Gait Ranch. I acknowledge the risks and potential for risks of horseback riding and other equine assisted services. However, I feel the possible benefits of myself/my son/my daughter/my ward are greater than the risk assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against Heaven’s Gait Ranch, Inc., its Board of Directors, Instructors, Trainers, Therapists, Aides, Volunteers, and/or Employees for any and all injuries and/or losses I/my son/my daughter/my ward may sustain while participating in programs at Heaven’s Gait Ranch.

Signature

Date

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Primary Contact in case of emergency

Phone

Secondary Contact in case of emergency

Phone

Physician’s Name

Physician’s Phone

Preferred Medical Facility

City

Health Insurance Co:

Policy #:

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Name

Phone

Date

Signature

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