Participant (rider) Form

Welcome!

We are excited you are interested in learning about our programs at Healing Strides! Please take the time to read through each release, so you fully understand. If you have any questions along the way, please reach out to our office at (540)334-5825.

This release is for those wanting to participate in any of the services offered at Healing Strides.
This form must be completed in its entirety to move to the next step.

Who are you filling this form out for? *

Basic Info

We use an online management tool for helping to communicate with all our contacts (we will NEVER sell or share your personal information!).

If you are filling this out for MULTIPLE dependents/children, you will need to fill a form out for EACH one individually (NOTE the email section below).

This info will be used to communicate program updates, special events, fundraisers and other important info from Healing Strides.

Make sure you have access to both the email account and the mobile for future contact. If you unsubscribe, we will no longer be able to communicate with you via emails and phone (this includes billing, scheduling, weather related closing, etc.). We CANNOT sign you back up once you unsubscribe.

First Name (self/child/dependent) *

Last Name (self/child/dependent) *

Nickname or preferred name for self/dependent/child:

Phone for self/guardian/parent of dependent/child listed above: *

I consent to receive SMS notifications, alerts & occasional marketing communication from Healing Strides. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Reason for visiting/filling out paperwork today? *

Field Trip/other explanation: (which school, troop, etc.)

Note: Please be aware of the directions given below about the same emails, for different people. Our system will see the same email as the SAME person and we will loose your data for multiple dependents/children.

Please do not reuse the same email for multiple dependents/children.

Option 1: EMAIL: STOP if you are filling this out for multiple dependents/children, DO put an email here ONCE (first time only), then leave this (option 1) blank for any additional dependents/children forms. On the next dependent/child's form, complete OPTION 2 (DIRECTLY BELOW) for any additional forms you complete (even if this is for you as your own form). If you are filling this out for yourself (and no one else!), please put your Email here and a name in option 2-

Please be sure you have access to this email, we will be sending next steps. (check you spam)

Option 2: If filling this form out for child/dependent, what is the NAME of GUARDIAN/PARENT and a good email here (do not put your email in the section above if you are filling this out for MULTIPLE dependents/children or addtonally yourself). If this is for yourself (and no other forms for others), please put your name *

Date of birth (self/child/dependent) *

Gender (self/child/dependent) *

Address *

Additional Address Info

City *

State *

Postal code *

Country *

Photo & Publicity Release

I consent to and authorize the use and reproduction by Healing Strides of VA of all photographs and any other audiovisual materials taken of myself/dependent(s)/Child(ren) for promotional material, educational activities, exhibitions, or for any other use for the benefit of the program.

Photo & Publicity Argreement Release *

Yes, I CONSENT to release my/my dependent/child photos/videos.

No, I DO NOT CONSENT to release my/my dependent/child photos/videos.

By checking one of these boxes you are agreeing to the statement selected.

Emergency Contact

Emergency Contact Name for myself/dependent/child *

Please enter First and Last Name of contact

Emergency Contact Relation to myself/dependent/child *

Emergency Contact Phone *

Please include Area Code in phone number.

Medical Waiver and Health Information

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving/giving services, or while being on the property of HSVA or activity site, I authorize Healing Strides of VA to: 1) Secure and retain medical treatment and transportation if needed. 2) Release client records upon request to the authorized individual or agency involved in the medical emergency treatment. This authorization includes X-Ray, hospitalization, medication and any treatment procedure deemed "life-saving" by the physician. This provision will only be invoked if the person consenting below is non-responsive in a medical emergency.

Medical Waiver and Health Information *

I agree to the Medical Waiver and Health Information statement above.

By checking this box, you are agreeing to the waiver above.

Pre-existing Health Conditions for self/dependent/child (put n/a if none) *

Please list any pertinent medication(s) you/dependent/child are taking (including medical marijuana) (put n/a if none) *

Please note any allergies and if EpiPen or inhaler is used (put n/a if none) *

What is your/dependent/child general health status? Tell us about any special needs or health concerns (ex. bad back, cannot be on feet long periods, etc.) *

Do you/dependent/child have health insurance?

Insurance Details - please put company and coverage dates

Have you/dependent/child ever been convicted of a crime?

If you/they have been convicted, please explain below:

General Liability Release

As a participant with Healing Strides of VA, I acknowledge and understand the risks and potential risks of a horseback and horse related activities in our program including but not limited to, (i) the propensity of an equine to behave in dangerous ways, which may result in injury or death to the participant or damage to property; (ii) the inability to predict an equine's reaction to sound, movements, objects, persons or animals; (iii) hazards of surface or subsurface conditions whether known or unknown; (iv) the condition and age of the equipment or tack, however, I feel that the possible benefits to myself and the participant I work with are greater than the risk I assume. I hereby, intent to be legally bound, for myself, my heirs and assigns, executors or administrators, and waive and release forever all claims for damages against-Healing Strides of VA, their board of directors, instructors, therapists, aides, volunteers, employees and their respective families, for any and all injuries and/or losses I may sustain while participating in Healing Strides of VA. I further certify that the foregoing statements and representations are being made by me knowingly, freely and voluntarily, and I understand that Healing Strides of VA is expressly relying upon the foregoing statements and representations in permitting me to participate in programs at Healing Strides of VA.

General liability Release *

I agree to the General Liability Release statement above.

By checking this box, you are agreeing to the Liability Release statement above.

Confidentiality

ACKNOWLEDGMENT OF HSVA CONFIDENTIALITY POLICY

* Due to the nature HSVA's programs, we are entrusted with sensitive personal information. Our clients are entitled to assurance of protection from unwarranted invasion of personal privacy. The Privacy Act, State and Federal Laws, regulations from licensing agencies and our basic constitutional rights are designed to protect us all from unwarranted invasion of privacy.

* No information about a client, including enrollment or residence, in written or any other form, may be disclosed to any person or organization without proper authorization. (The only exception is in a life-threatening emergency, in which necessary medical information may be disclosed to emergency personnel to expedite treatment). HSVA staff is responsible for reviewing all requests for information to ensure that the proper authorization has been obtained.

* Again, our records contain sensitive client information, which is protected by law from unauthorized disclosure. HSVA holds the moral and legal obligation to protect the interests of both our clients and employees. By signing the confidentiality agreement, I commit to protect the privacy of HSVA clients, both past and present.

* I have read the above and agree to maintain this policy during and after my tenure with HSVA. I realize that this document will become a permanent record at HSVA. I further realize that failure to comply with the policies on confidentiality could impact my involvement at HSVA.

Consent to Electronic Signature

By checking this box you consent to an electronic signature. *

I consent to Electronic Signature for myself/dependent/child

You are agreeing to be legally bound by your electronic signature for everything in this above form.

Signature of Individual (18 years or older)/Parent/Guardian for the above described dependent/child *

Clear

This form is for participation in our "riding" program. The entire form must be completed for EACH individual wanting to join our programs.
Healing Strides of VA is an Educational Facility.

You are participation in a mission focused program. Therapeutic

Horsemanship Lessons are taught by PATH Certified Instructors and/or Instructors-In-Training. Each group lesson will last 50 minutes.

All lessons will be scheduled through the Scheduling Coordinator (540/334.5825).

Tuition Based Programing:

* Therapeutic Horsemanship: $60.00 per lesson

* HSVA Horsemanship Club: Contact the Office for more information

- All Fees are non-refundable. Tuition will not be prorated for any circumstances. Full tuition is due at the beginning of each session. (Ex: 10- week session = $600.00). If you are unable to pay in full at the beginning of a session, contact our Admin Office regarding other arrangements.

If you need a Scholarship Application, please ask for one.

- Tuition can be mailed or placed in the lock box inside the main building. All payments (check or cash) need to be placed in an envelope with the first and last name of participant and what program/lesson you are paying for.

- In the event the participant registered decides to discontinue lessons at any time, you are required to inform HSVA by phone or mail. No refunds will be distributed.

By checking this box, you are agreeing to the above tuition based policy.

I have read and agree to the TUITION BASED policy.

Make-Up Lesson Policy:

- There are No make-up lessons

- HSVA reserves the right to cancel, reschedule, combine or reduce class time due to low enrollment, weather, absence of other participants, or unforeseen circumstances. Any class that has one student will be a half hour private*.

If HSVA must close due to weather or unforeseen circumstances, we will change our office message machine and our FB page.

Notice of Absence: Notice of absence must be made by one (1) of the following methods:

> In person at the Admin Office

> Email to [email protected]

> Call (540) 334-5825 – please leave a DETAILED message

Notice of absence to an instructor is not considered notice to the Admin Office for billing or attendance purposes.

By checking this box, you are agreeing to the above Make-up based policy

I've read and agree to the MAKE UP policy.

School or Occupation? (please put n/a if not applicable) *

Please list any equine experience: (be as clear as possible) *

Grade/Level of schooling? *

Healing Strides Mission:

To promote wellness for people with personal challenges who can benefit from equine assisted activities and therapies in a safe and supportive environment.

Healing Strides’ mission serves to create opportunities for individuals, families, and groups in our community to partner with horses to create lasting change in their lives. While our staff is certified to instruct participants of all abilities, including adaptive and therapeutic participants, our horsemanship program is inclusive to anyone who wants to have a relationship with horses. Our priorities are teaching our participants safety, communication, building relationships, and accountability with horses through safe and effective horsemanship.

At Healing Strides, we specialize in providing services to children and adults with a wide range of disabilities and diagnoses, though our mission extends beyond any diagnostic parameters to anyone with personal challenges, both temporary and long-lasting. Horsemanship and horseback riding are recreational activities that can have therapeutic benefits to anyone involved in them.

With our mission in mind, we ask that you share two personal challenges below that can be included in the participant progress goals during all lessons. These challenges can be big or small, short or long-term, physical, emotional, or behavioral. Often these goals can be related to school (ABCs, colors, shapes, reading, focus, etc), coping and resiliency skills (managing emotions, remaining calm and present, etc), physical goals (balance/coordination, muscle tone, strength, etc), relating to a diagnosis or disability (TBI, ASD, sensory processing, social skills, etc), or really anything at all.

What are your/dependents/children's TWO personal challenges? *

This is required to participant in any programs at Healing Strides.

What is your/dependents/child's previous riding experience? *

Yes, we know this is long! Please power through and complete to the end! You are almost there!
physical/cognitive abilities

Physical Limitations (if any), please tell us a bit about you/dependent/child's abilities and/or limitations: *

Please put N/A if not applicable.

Adaptive equipment? *

Please select N/A if not applicable.

Communication Style: (please select all the apply): *

Please explain "other" communication style:

What motivates you/dependent/child? (ex. food, public praise, competition, etc.) *

Do you/dependent/child have any behaviors we need to be aware of? (physical violence, tics, melt-downs, etc.) *

Do you/dependent/child have sensitivities or aversions to any specific textures, loud noises, bright lights, other? *

Are you/dependent/child in any therapies? (n/a if not applicable)

Anything else we would need to know about you/dependent/child? *

There is no guarantee, but we try to accommodate everyones schedules as best we can: Please select the day(s) that would be ideal for you/your dependent?

Please select the ideal time of day: (mornings/mid-day are most available)

I authorize the release of this information to Healing Strides of VA’s staff and volunteers, on a need to know basis: *

By checking this box, you are agreeing to the above statement.

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