<p> Take this form to your local emergency room to ensure that all pertinent information is present. Participant’s Application & Health History</p><p>GENERAL INFORMATION Participant Name:______DOB: ______Age: ______Height: ______Weight: ______Gender: M___ F___ Address: ______Phone: ______E-mail: ______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: Yes/ No ( if answered yes, please add comments): Vision:______Hearing:______Sensation:______Communication:______Heart:______Breathing:______Digestion:______Elimination:______Circulation:______Emotional/Mental Health:______Behavioral:______Pain:______Bone/Joint:______Muscular:______Thinking/Cognition:______Allergies:______Page 1 of 2 pages Participant’s Application & Health History (Page 2 of 2 pages) Participant’s Name:______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: ______Date: ______PHOTO RELEASE I DO____ DO NOT____ consent to and authorize the use and reproduction by Macon TRACS, Inc. of any and all photographs and any other audio/visual materials taken of me and my family for promotional material, educational activities, exhibitions or for any other use for the benefit of the program. Signature: ______Date: ______Client, Parent or Legal Guardian Signed in the presence of center staff</p><p>Macon TRACS, Inc. Therapeutic Riding for Adults’ and Children’s Success P.O. Box 101, Otto, NC 28763 828-349-6262 </p>