Dear Participant,

Enclosed, please find the registration packet for the Kids & Horses program. Kids & Horses currently offers three services: adaptive riding, physical therapy and occupational therapy.

Adaptive Riding, taught by a certified instructor, consists of weekly 60-minute horseback riding lessons tailored to students with special needs. There are many therapeutic benefits that come with learning how to ride a horse. The fee for adaptive riding is $50.00 per lesson. Tuition will be billed at the end of each month and is due within 30 days. We will bill Nevada Accumen, FEAT, or other organizations if the student receives funding from one of these agencies. A limited number of scholarships are available. Please contact the office to receive a scholarship application if needed. If the student is more than 10 minutes late, he/she will not be allowed to participate and will be charged $50 for the lesson. Students will be also charged $50 for no-showing. Please be sure to notify us as soon as possible if the student will not make it to their lesson (24 hours preferred). If a student is absent two times in a session without prior notification for the absence, the student will be excused from the program.

Physical Therapy targets skills such as balance, strength, and coordination to reach functional goals such as improved walking, stair climbing or running in a game of soccer. Occupational Therapy treatments focus on fine motor, gross motor and/or sensory integration skills such as what is needed to fasten a button, write a sentence, tolerate haircuts or focus on a school assignment. Both therapies provide weekly 60-minute sessions. Goals are addressed while riding a horse for half the session and participating in traditional treatments in a therapy room for the other half. The cost varies, depending on the client’s medical insurance plan. We accept Medicaid, Hometown Health, and several other insurance plans. Please speak to a therapist to determine your cost and establish a plan.

We welcome family involvement and provide on-the-job training. You do not have to be horse savvy to volunteer. Help us keep our operating costs down by becoming an integral part of the program.

Happy Trails,

Kids & Horses

Kids & Horses Inc. Phone: (775) 267-1775 Email: info@kidsandhorses.org

2869 Esaw Street, Minden NV 89423 Fax: (775) 267-2349 Website: www.kidsandhorses.org

General Information and Health History

Participant: *

Date of Birth: *

Age: *

Weight: *

Height: *

Gender: *

Address: *

Phone: *

Email: *

Name of Parent/Legal Guardian(s) (if applicable):

Address of Parent/Legal Guardian(s) (if different than above):

Goals (What would you like to accomplish?): *

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Diagnosis/Diagnoses *

Current Medication: *

Comments:

Participant's Name: *

Photo Release: *

I consent to authorize the use and reproductions by Kids & Horses, Inc. of any and all photographs and any other audiovisual materials taken of me or my child for promotional printed material, educational activities, exhibitions, website, Facebook or for any use for the benefit of the program.

I do NOT consent nor do I authorize the use and reproductions by Kids & Horses, Inc. of any and all photographs and any other audiovisual materials taken of me or my child for promotional printed material, educational activities, exhibitions, website, Facebook or for any use for the benefit of the program.

Signature of Participant or Parent/Legal Guardian *

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Date: *

Liability Release

Participant's Name *

would like to participate in the Kids & Horses program. I acknowledge the risk and potential for risks of horseback riding and being around horses. However, I feel that the possible benefits to my son/daughter/, my ward or myself are greater than the risk assumed. I, hereby, intend to be legally bound for myself, my heirs and assigned executers or administrators. I waive and release, forever, all claims for damages against Kids & Horses, Inc., its Board of Directors, Instructors, Therapists, Aides, Volunteers and/or employees for any and all injuries and/or losses, my son/daughter, my ward or I may sustain while participating in the Kids & Horses program.

Signature of Participant or Parent/Legal Guardian *

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Policy of Confidentiality:

I agree to respect and observe privacy and confidentiality of the participants, volunteers and donors of Kids & Horses, Inc. and not discuss any sensitive information about any person or their family.

Signature of Participant or Parent/Legal Guardian *

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Date: *

Authorization for Emergency Medical Treatment for Participants

Participant's Name: *

Phone: *

In case of emergency contact:

Name: *

Relation: *

Phone: *

Name:

Relation:

Phone:

Physician's Name: *

Physician's Phone: *

Email: *

City: *

Preferred Medical Facility: *

Health Insurance Carrier: *

Policy #: *

Please Indicate Any Allergies: *

Current Medications: *

Consent Plan:

I give consent for emergency medical treatment/aid (including x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life saving” by the physician). In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, any participation on my part at Kids & Horses, Inc., or while being on the property of Kids & Horses, Inc., I authorize Kids & Horses, Inc. to :

Secure and retain medical treatment and transportation, if needed.
Release records upon request to the authorized individual or agency involved in the medical emergency treatment.

NON-Consent Plan: I do NOT consent for emergency medical treatment/aid in the event of illness or injury during the process of receiving services, any participation on my part at Kids & Horses, Inc. or while being on the property of Kids & Horses, Inc. In the event emergency medical treatment/aid is required, I wish the following procedures to take place:

Consent

Non-Consent

Signature of Participant or Parent/Legal Guardian

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Date:

Employment Information

Dear Participant or Parent/Legal Guardian,

Please provide your current emplyment information.

Name: *

Employer: *

Employer Phone: *

Employer Address: *

Name:

Employer:

Employer Phone:

Employer Address:

Safety

Please do:

Wear long comfortable pants and closed-toed shoes, preferably heeled boots. If you do not have heeled boots, we have a variety of sizes available that you may use. If you do not wear long pants, you will not be allowed to ride. Your instructor will provide an alternate activity.
Be ready to ride at your designated time. Arrive at the ranch a few minutes early to put on your helmet and/or boots. If you are 10 minutes late, your lesson will be canceled and it will be considered an unexcused absence.
Notify us at least 1 hour (preferably 24 hours) in advance if you are unable to attend your lesson. If you are absent 3 times in a season without a valid excuse and timely notification of your absence, you will be removed from the program.
Obey the 25 MPH speed limit on Esaw Street and 10MPH on the ranch property.
If applicable, have your parent/guardian stay on the premises.

Please do not:

Enter areas marked “Horses Only Beyond this Point,” “Keep Out” or “Authorized Personnel Only”.
Smoke anywhere on the ranch property.
Call out instructions to your child during his/her lesson. This creates a distraction and comprises safety of all participants in the arena.
Expect staff and/or volunteers to assume responsibility for the participant prior to or after the lesson/ therapy session.

Safety Rules:

Parents MUST provide supervision for siblings and guests of student for their safety. An adult must accompany all children at ALL times.
Do not pet or feed any treats to the horses.
Participants are not allowed in the barn aisle (grooming/tacking area) unless under direct supervision of a staff member.
ASTM-SEI helmets must be worn by participants when grooming, handling or riding a horse.
No cell phones allowed while observing or participating in lessons.
Instructors/ therapists and/or authorized personnel must supervise all mounting and dismounting procedures.

I have read and understand the safety rules.

Signature of Participant or Parent/Legal Guardian *

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Date: *