New Participant Application - 5/22/2020 Program InformationDate* Date Format: MM slash DD slash YYYY Participant Name* First Last Phone*DOB* Date Format: MM slash DD slash YYYY Age*Please enter a number from 4 to 99.Height*Weight*Gender*MaleFemalePrimary Diagnosis*Secondary DiagnosisVeteranNoYesIf yes, what branch of service?If yes, are you affiliated with the Wounded Warrior Project?NoYesMobility status (walks unassisted, assistive devices, etc.)Communication (verbal, non-verbal, signs)Behaviors (impulsive, fearful, frustration tolerance)Medications takenSeizures (if applicable please describe)LimitationsAllergies, Asthma, etc.Skin sensitivityParticipant’s occupation/ school grade levelPersonal GoalsOtherAvailibility for the TROT Program(Please check all that apply)Morning Classes 8:00 am to 10:45 am Monday AM Tuesday AM Wednesday AM Thursday AM Friday AM Afternoon Classes 4:00 pm to 6:30 pm* Monday PM Tuesday PM Wednesday PM Thursday PM Friday PM *How did you hear about TROT? Internet Flyer Referred by:Participant Contact and Tuition InformationParticipant Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhoneEmail* Guardian (1)* First Last Relationship*Cell Phone*Work PhoneEmail* Guardian (2) First Last RelationshipCell PhoneWork PhoneEmail Medical Emergency Contact InformationIn the event of a medical emergency, TROT will provide basic first aid and/or call 911 and will disclose all available health care information to emergency medical personnel.Best Emergency Contact Name* First Last Phone*Relationship to Participant*Other Phone #*Preferred Medical Facility:*Physicians Name:* First Last Health Insurance Company:*Policy #*Program Tuition Payment Details$45 One Time Assessment FeePlease tell us how you will be paying:* Check (please make payable to TROT) Credit Card (please call TROT at (520) 749-2360 x600 to pay by credit card) I understand and agree that all paperwork must be up to date. All tuition is to be paid prior to the start of each semester or on the first day of class in full ($540) or in three (3) monthly installments of ($180). If applicable, all scholarship forms must accompany the rider application.Date* Date Format: MM slash DD slash YYYY Participant or Legal Guardian* First Last Tuition Payment Consent* I understand and agree to TROT's Tuition Payment policy.Participant Liability, Confidentiality Agreement, Photo and Video ReleaseLiability Release: I acknowledge the risks and potential risks for horseback riding and activities in and around a facility where horses are kept, and farm machinery operated. However, I feel that the possible benefits to me/child/my ward are greater than the risk assumed. Intending legally to bind myself, my heirs, and assigns, executors or administrators, I hereby waive and release forever all claims for loss or damages of any kind against TROT, its Board of Directors, Instructors, Therapists, Aids, Volunteers and Employees for any and all injuries and losses that I/my child/my ward may sustain while participating in the TROT program. This release includes without limitation the risk of negligent instruction and supervision. I engage in activities at TROT voluntarily with knowledge of the risks and I assume all risks of injury, death, and property damage that may result. I agree to bear any loss myself. I acknowledge that TROT and the property owners are materially relying on this waiver and assumption of risk in allowing me/my child/my ward to participate in activities at TROT. Liability Release Consent* I agree to the TROT Liability Release Agreement.Confidentiality Agreement: I understand that all the personal information (written and verbal) about participants at TROT is confidential and not to be shared with anyone without expressed written consent of the participant or their parent/guardian if a minor. Confidentiality Agreement Consent* I agree to the TROT Confidentiality Agreement.Photo and Video Release: The use and reproduction by TROT of any audio/visual materials taken of me/my child/my ward for distribution to the public for promotional printed materials, educational activities or for any other use for the benefit of the program. Photo and Video Release:*I DO consent to TROT's Photo and Video Release: AgreementI DO NOT consent to TROT's Photo and Video Release: AgreementReasons for DischargePlease be advised of the following reasons that may lead to discharge from the riding program. 1. The client has reached all of their goals and is ready to graduate. 2. The client’s potential to maintain head and neck control while riding presents a safety concern. 3. The inability to follow directions is interfering with progress toward goals. 4. Uncontrolled and/or inappropriate behavior that constitutes a safety risk to a client, staff, and/or horse. 5. The client exceeds weight staff, volunteers, and/or horses can safely manage that. 6. Any change in the client’s medical, physical, cognitive, or emotional condition that makes therapeutic riding inappropriate. 7. Three scheduled appointments are missed without prior cancelation. 8. Disruptive behavior that is counterproductive to the benefit of anyone equine or human at TROT. 9. Any purposeful act of compromised safety related to any equine, human or self at TROT. 10. No longer suited, willing or able to perform activities at TROT safely or as directed. 11. Non-payment of fees, as originally agreed.Procedure: a) All participants/volunteers/guests who meet the criteria of dismissal will be asked to meet with the Volunteer Coordinator and Program Director to discuss the behavior/issue in question. b) The Volunteer Coordinator and Program Director will work to educate and outline the appropriate expected behavior of the participant/volunteer/guest at TROT. c) If the participant/volunteer/guest is willing to perform the expected behavior/task, then support and further education will be implemented by the TROT staff. d) If the participant/volunteer/guest is not receptive to the expectation of behavior, the volunteer will be asked to leave the TROT program. Therefore, dismissed from the TROT property or returning in the future without permission. e) The participant/volunteer/guest will be sent a signed, dated letter confirming the expected actions as a result of the meeting. f) An additional copy of the letter will be printed and placed in the participants /volunteer’s file. Reasons for Discharge Consent I understand and agree to TROT's Reasons for Discharge policy.