Skip to content
Toggle Navigation
Home
About
Staff
Our Herd
Board of Directors
History of TROT
Programs
Volunteer
Volunteer Login
Events
Resources
TROT Forms
Hoof Prints
Donate
New Adaptive Riding Participant Application
cjkeeme
2022-09-26T12:23:30-07:00
moving without the hassle
WE MAKE IT SIMPLE
professional service with quality and customer satisfaction
New Adaptive Riding Participant Application - (6/2023)
TROT Policies
Before completing this application, please open and read TROT's updated policy and procedure guide. By submitting this application, you acknowledge and agree to TROT's Terms and Conditions within the updated Policy and Procedure Guide.
READ TROT'S UPDATED POLICY AND PROCEDURE HERE
Please select...
I DO Agree
I DO NOT Agree
Applicant Information
Participant First and Last Name
Address
City
State
Zip
DOB
Gender
Please select...
Male
Female
Transgender
Non-binary/non-conforming
Race and Ethnicity
Please select...
American Indian or Alaskan Native
Asian
Black or African American
Caucasian
Hispanic
Native Hawaiian or Other Pacific Islander
Other
Prefer not to disclose
Is the Applicant a Veteran/First Responder or a dependent of?
Please select...
Yes
No
If yes, what branch of service?
Please select...
Army
Navy
Marine Corps
Air Force
Coast Guard
Space Force
Are you affiliated with the Wounded Warrior Project?
Yes
No
Personal Health Information
Age
Weight
Height
Primary Diagnosis
Secondary Diagnosis
Mobility Status
Please select...
Walks Unassisted
Needs Assistance
Utilizes Mobility Device
Communication
Please select...
Verbal
Verbal-Limited
Non-Verbal
Uses Sign Language
Behaviors (Impulsive, fearful, frustration tolerance)
Medications taken
History of Seizures
Please select...
Yes
No
Seizures (if applicable please describe)
Precautions/Limitations
Allergies, Asthma, Skin Sensitivity, etc.
Applicant's occupation/school grade level
Personal Goals
Physical Goals
(i.e. increase balance, core strength, endurance, flexibility, coordination, accuracy, etc.)
Cognitive Goals
(i.e. improve reasoning, problem solving, analytic skills, comprehension, word recognition, precision, demonstration of understanding, social language skills, self-expression, etc.)
Emotional Goals
(i.e. improve overall emotional well-being, emotional regulation, accepting NO, recognizing signs of frustration, convey emotional appropriately, etc)
Behavioral Goals
(i.e. ability to manage conflict, demonstrate self-regulation, take a break when needed, understanding personal space, easier transitions, etc.)
Contact Information
Primary Contact Full Name
Relationship to Participant
Preferred Phone
Email
Secondary Contact Full Name
Relationship to Participant
Cell Phone
Email
Medical Emergency Contact Information
In 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.
Emergency Contact is same as Primary Contact
Please select...
Yes
No
Best Emergency Contact Name
Phone
Relationship to Participant
Preferred Medical Facility
Physician's Name
Health Insurance Company
Policy #
Participant Liability, Confidentiality Agreement, Photo and Video Release
Liability 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 Director, Instructors, Therapists, Aids, Volunteers and Employees for al 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 allowing me/my child/my ward to participate in activities at TROT.
Liability Release Consent
I agree to the TROT Liability Release Agreement
Today's Date
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 of their parent/guardian if a minor.
Confidentiality Agreement Consent
I agree to the TROT Confidentiality Agreement
Today's Date
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.
I DO NOT consent to TROT's Photo and video Release
Today's Date
How did you hear about TROT?
Please select...
Newspaper
Online Search
Other
Physician Referral
Radio
Social Media
Therapist Referral
Word of Mouth
Contact Information
Page load link
Go to Top