Horsin Around Club

Dear Parent/Guardian or Adult Applicant:

EASI is pleased that you are interested in participating in our program! Our sessions last four weeks. Riders are scheduled once per week for approximately 30 minutes to one hour, depending on rider tolerance. Classes are held Monday-Thursday. We hope you will be able to participate in our program. Horseback riding and other activities involving horses can be one of the most effective and enjoyable forms or therapy available. However, horseback riding is not for everyone, and there are risks involved. Therefore, several requirements must be fulfilled and several forms must be completely filled out before any student begins riding. Some of the information is of a personal nature and assists us in determining whether horseback riding would be a safe and effective activity for the student. The forms are only viewed by the administrative personnel, the instructor, and the therapists evaluating the student. The only information shared with volunteers is that which is pertinent to the student’s progress during the riding lesson. Volunteers are required to sign an agreement not to discuss personal information outside the lesson.

The following forms are attached: ● Participant’s Application and Health History with Physician’s Statement This form will assist EASI administrative staff in determining participant eligibility. A physician’s release must be completed and signed by the student’s physician annually. The physician must address precautions and contraindications for the student to be safely involved in the physical aspects of riding. For Participants with Down Syndrome EASI requires certification by a physician, prior to riding and annually thereafter, that a medical examination with specific reference to neurologic function and initial lateral or side view x-rays of the upper cervical region in full flexion and extension did not reveal Atlantoaxial Instability or focal neurologic disorder. This form is found on the Physician’s Statement. ● Participant’s Registration and Release Form A liability release must be signed by the parent/guardian or adult participant that releases EASI from liability in case of an accident. EASI will also take photos/videos for a variety of reasons. Participants may choose to have their pictures taken or not. ● Authorization for Emergency Medical Treatment Consent/Non-consent Authorization giving or refusing permission for emergency medical treatment must be obtained in writing from the adult participant or the student’s parent/guardian. ● Policy of Eligibility Requirements for Participation/Ongoing Participation The primary concern is that each program provides a safe and productive experience for all participants. At the fore is the assertion to “do no harm.” The entire team – participant, parent/guardian, PATH Intl. instructor, therapist(s), educator, and physician – must be comfortable with the decision to participate or not.

PLEASE NOTE: missed lessons without prior notification will be charged a fee with the possibility of dismissal.

●Fee EASI is a 501(c) (3) nonprofit organization. We strive to provide services to all, regardless of the ability to pay. Any donations you can provide are greatly appreciated. Local businesses often are willing to provide sponsorships for riders ($100.00 for a 4 week session). Remember, donations are 100% tax deductable (receipts are available.)

Please return completed form to EASI, 242 Summerville Road, Jasper, Alabama 35504. If you have any questions, please call (205) 387-7486. Thank you for your interest in our program. Page 1 of 9 2016

242 Summerville Road  Jasper, AL 35504  205-387-7486  easitrc.org Orientation Initials Scheduled:______Completed:______Participant’s Application and Health History

General Information

Participant’s Name:______Date of Birth:______Age:______

Height:______Weight:______Gender: M F

How did you hear about the program?______

Employer/School/Group Association______

Health History

Diagnosis:______Date of Onset:______

Comments:______

Please indicate current or past special needs in the following areas, including surgeries: YES NO Comments Vision Hearing Tactile Sensation Speech/Communication Integumentary/Skin Immunity Heart Circulation Breathing Digestion/Elimination Emotional/Psychological Behavioral Pain Bone/Joint Muscular Thinking/Cognitive Allergies

242 Summerville Road  Jasper, AL 35504  205-387-7486  easitrc.org Page 2 of 9 2016

242 Summerville Road  Jasper, AL 35504  205-387-7486  easitrc.org Participant’s Application and Health History Page 2

Medications: (include prescription, over the counter; name, dose, and frequency)

Note: Use discretion. Information regarding medications which may cause drowsiness or alter activity level could aid instructors/therapists in identifying program effectiveness. List only these medications. ______

Describe your abilities/difficulties in the following areas (include assistance required or equipment needed):

Physical Function: (i.e. mobility skills such as transfers, walking, wheelchair use, driving/bus riding) ______

Psycho/Social Function: (i.e. 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:______Date:______

of 9 2016

242 Summerville Road  Jasper, AL 35504  205-387-7486  easitrc.org Participant’s Application and Health History Page 3

Physician’s Statement To my knowledge there is no reason why ______cannot participate in supervised equestrian activities. However, I understand that the therapeutic riding center will weigh the medical information below against the existing precautions and contraindications. I concur with a review of this person’s abilities/limitations by a licensed/credentialed health professional (e.g. PT, OT, SLP, Psychologist, etc.) in the implementing of an effective equestrian program. For participants with Down Syndrome A medical examination with specific reference to neurologic function and initial lateral or side view x-rays of the upper cervical region in full flexion and extension did not reveal Atlantoaxial Instability or focal neurologic disorder.

Physician’s Name/Title:______

Physician’s Signature:______Date:______

Address:______City:______State: ______Zip:_____

Phone:______Information for Physician The following conditions, if present, may represent precautions or contraindications to therapeutic horseback riding. Therefore, when completing this form, please note whether these conditions are present, and to what degree. Orthopedic Medical/Surgical Spinal Fusion Allergies Spinal Instabilities/Abnormalities Cancer Atlantoaxial Instabilities Poor Endurance Scoliosis Recent Surgery Kyphosis Diabetes Lordosis Peripheral Vascular Disease Hip Subluxation and Dislocation Varicose Veins Osteoporosis Hemophilia Coxas Arthrosis HypOertension Heterotopic Ossification Serious Heart Condition Osteogenesis Imperfecta Cranial Deficits Spinal Orthoses Internal Spinal Stabilization Devices Secondary Concerns Behavior Problems Neurologic Age less than two (2) years Hydrocephalus/shunt Age two (2) – four (4) years Spina Bifida Acute exacerbation of chronic disorder Tethered Cord Indwelling catheter Chiari II Malformation Hydromyelia Paralysis due to Spinal Cord Injury

242 Summerville Road  Jasper, AL 35504  205-387-7486  easitrc.org Seizure Disorders Page 4 of 9 2016

242 Summerville Road  Jasper, AL 35504  205-387-7486  easitrc.org Participant’s Registration and Release Form

Registration

Participant’s Name: ______Date of Birth:______Age:______

Address:______City: ______State: ______Zip: ______

Home Phone: ______Other Phone: ______e-mail: ______

Parent(s)/Legal Guardian/Caregiver(s): ______

Address (if different from above): ______

Home Phone: ______Other Phone: ______

Photo Release

I □ DO

I □ DO NOT Consent to and authorize the use and reproduction by EASI of any and all photographs and any other audio/visual materials taken of me/my child for promotional material, educational activities, and exhibitions or for any other use for the benefit of the program.

Signature: ______Date: ______

NOTE: Any person who photographs any individual in the EASI program must obtain a signed “EASI Photo Release For Personal Use” form signed by person(s) photographed and an EASI representative before posting on any website or otherwise displaying for public view.

Liability Release ______would like to participate in the EASI program. I acknowledge the risks and potential for risks of horseback riding and related activities. However, I feel that the possible benefits to me/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 Equines Assisting Special Individuals (EASI), its Board of Directors, Instructors, 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 the EASI program. Signature: ______Date: ______

242 Summerville Road  Jasper, AL 35504  205-387-7486  easitrc.org Participant’s Registration and Release Form Page 2 Page 5 of 9 2016

242 Summerville Road  Jasper, AL 35504  205-387-7486  easitrc.org Authorization for Emergency Medical Treatment □ Participant □ Staff □ Volunteer

Name: ______Physician’s Name: ______

Preferred Medical Facility: ______

Health Insurance Company: ______Policy Number: ______

Allergies to medication: ______

Current Medications: ______

In the event of an emergency, contact:

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 EASI to:

1. Secure and retain medical treatment and transportation if needed. 2. Release participant/volunteer/staff records upon request to the authorized individual or agency involved in the medical emergency treatment.

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.

Signature: ______Date: ______Participant/Staff/Volunteer, 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 being on the property of the agency. ●In the event emergency treatment/aid is required, I wish the following to take place: ______

Signature: ______Date: ______Participant/Staff/Volunteer, Parent or Legal Guardian Page 6 of 9 2016

242 Summerville Road  Jasper, AL 35504  205-387-7486  easitrc.org Policy of Eligibility Requirements for Participation

Mission Statement: Equines Assisting Special Individuals (EASI) is a nonprofit organization dedicated to providing safe and therapeutic riding activities for individuals with disabilities and special needs in Walker County and the surrounding areas.

The primary concern is that each program provides a safe and productive experience for all participants. At the fore is the assertion to “do no harm.” Recognizing that activities with equines do hold inherent risks, we need to assess an individual’s participation with a “Risk/Benefit” analysis. The essential question for everyone is, “Will the benefit of the equine activity outweigh the risk?” This question must be answered with consensus by the entire team – participant, parent/guardian, PATH Intl. instructor, therapist(s), educator, and physician.

All members must be comfortable with the decision to participate or not, by being familiar with all pertinent information.

Considerations include, but are not limited to, the following:

1. Most equine activities inherently involve movement. The movement activity should not cause a decrease in the participant’s function, an increase in pain or generally aggravate the medical condition.

2. The essence of equine activities is the human-animal connection. This interaction should not be detrimental to the participant or the equine.

3. Equine activities require the use of certain equipment in a prescribed environment and are, by definition, interaction with an equine. EASI must be able to accommodate the participant’s equipment needs. If the environment will aggravate his condition, equine activities may not be appropriate.

4. Mounted activities always present the potential for a fall. In most cases, the fall would be from four to six feet above the ground. Such a fall may cause a greater functional impairment than the participant originally had. The possibility of a fall should be given careful consideration, and may lead to the informed decision that mounted activities are not the activity of choice.

5. Working around equines (i.e. grooming, leading, etc.) involves risks. Even the well-trained equine is subject to its instinctive fight or flight responses. Equines are large, move quickly, and can be dangerous to the participant who is unable to respond appropriately.

6. Equine activities involve a team approach. Team members usually include the equine, the PATH Intl. instructor, sidewalkers/helpers, and additional professionals as needed. The training, performance, and communication skills of the team must allow for a safe and effective session.

of 9 2016

242 Summerville Road  Jasper, AL 35504  205-387-7486  easitrc.org Policy of Eligibility Requirements for Participation Page 2

7. EASI must have the numbers and quality of staff necessary to capably serve a participant before acceptance into the program is approved.

8. Important considerations of the equine are: temperament, gait, age, health, conformation, energy level, responsiveness, sensitivity and level of training. A suitable equine must be available to meet the needs of the participant before acceptance is made.

9. Facilities and equipment are important considerations when accepting a participant into the program. If the participant’s needs cannot be met in this area, participation is contraindicated.

10.If a participant’s weight or height exceeds the capability of the equine or volunteers available, participation is not recommended.

11.Participants must be 2 years of age or older.

12.All potential participants are required to complete a Participant Packet, which includes Participant’s Application and Health History with Physician’s Statement, Participant’s Registration and Release of Liability Form, and Authorization for Emergency Medical Treatment Consent/Non-Consent Form. Incomplete forms will not be accepted.

13.All participants are required to wear protective headgear that is American Society for Testing and Materials – Safety Equipment Institute (ASTM-SEI) approved for equestrian use while mounted or driving. Alternative helmets (helmets not ASTM approved for equestrian activities) may be acceptable under very specific circumstances.

14.Medical Precautions and Contraindications The PATH Intl. Health and Education Committee periodically reviews a list of conditions and diagnoses which serves as a guide to PATH Intl. centers when determining eligibility of participants. However, it is the responsibility of the entire team to determine whether equine activities are inappropriate or unsafe. The New American Webster Handy College Dictionary (1995) defines precaution as “an act done in advance to assure safety or benefit.” The presence of a precaution requires “measures” of additional investigation – such as contacting the physician or therapist before accepting a participant into a program. It may require modification of the program, additional equipment, and always requires re-evaluation at regular intervals to assure the appropriateness of the program. The presence of a contraindication makes this activity inappropriate. A contraindication may be permanent. For instance, some activities may never be appropriate for certain participants due to safety or health concerns. A contraindication may be temporary. Activities may only be contraindicated until appropriate conditions exist at EASI or until a participant’s health condition improves enough to make participation safe. If a particular activity is contraindicated, alternative equine activities may be explored. Page 8 of 9 2016

242 Summerville Road  Jasper, AL 35504  205-387-7486  easitrc.org Policy of Eligibility Requirements for Ongoing Participation

Mission Statement: Equines Assisting Special Individuals (EASI) is a nonprofit organization dedicated to providing safe and therapeutic riding activities for individuals with disabilities and special needs in Walker County and the surrounding areas.

The primary concern is that each program provides a safe and productive experience for all participants. At the fore is the assertion to “do no harm.” Recognizing that activities with equines do hold inherent risks, we need to assess an individual’s participation with a “Risk/Benefit” analysis. The essential question for everyone is, “Will the benefit of the equine activity outweigh the risk?” This question must be answered with consensus by the entire team – participant, parent/guardian, PATH Intl. instructor, therapist(s), educator, and physician.

All members must be comfortable with the decision to continue participation or not, by being familiar with all pertinent information.

The decision making process used to determine ongoing participation is the same for determining participant acceptance to a PATH Intl. center. However, people and situations change. Participant’s interest can change, their disability may improve or worsen, or other difficulties can develop. EASI staff will periodically review participant’s status.

Riders at EASI may be asked to leave the program for a number of reasons, including, but not limited to, the following:

1. The development of a contraindicated condition or the deterioration of a condition to the point that therapeutic riding is no longer beneficial or could be harmful to the rider or where safety for the rider or others has become a concern. 2. Weight gain above the amount in which EASI can service safely. 3. Incomplete annual forms (Registration, Liability, and Photo Releases, Authorization for Emergency Medical Treatment, Consent for Release of Information, and Physician-signed Medical Form). 4. A display of fire-starting, threatening behavior, animal abuse, the physical or verbal abuse of others, alcohol or drug use on grounds, or behavior that is disruptive to the normal functioning of the program. 5. Frequent missed lessons, without advance notification. (No more than 2 per session, with a maximum of 6 per calendar year). PLEASE NOTE: A fee will be charged for all lessons missed without prior notification. 6. Mainstreaming of an advanced independent rider whose riding has progressed beyond the ability of our program horses.

The instructors will handle all dismissals. A written reason for dismissal will be recorded in the rider’s file. The grounds for dismissal will be discussed with the rider and/or parent/guardians in private. Riders or parents/guardians may appeal the dismissal in writing at the next Board of Directors meeting, but the decision of the Board will be final. Page 9 of 9 2016

242 Summerville Road  Jasper, AL 35504  205-387-7486  easitrc.org