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Rider Application

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT


Name: DOB: Phone:________________________
Address:
Physicians Name: Preferred Medical Facility:
Health Insurance Company: Policy #:
Allergies to Medications:
Current Medications:
In the event of an emergency, contact:
Name: Relation: Phone:
Name: Relation: Phone:
Name: Relation: Phone:

In the event emergency medical aid/treatment is required due to illness or injury during the process of
receiving services, or while being on the property of the agency, I authorize Danielle Inman Adaptive
Riding 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.

Consent Plan: This authorization includes x-ray, surgery, hospitalization, medication and any
treatment procedure deemed life-saving by the physician. This provision will only be invoked if the
person(s) above is unable to be reached.
Date: Consent Signature:
(Client, Parent or Legal Guardian Signed in presence of center staff)

Non-Consent Plan:
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during
the process of receiving services or while being on the property of the agency.
Parent or legal guardian will remain on site at all times during the equine assisted activities
In the event emergency treatment/aid is required; I wish the following procedure to take place:



Date: Consent Signature:
(Client, Parent or Legal Guardian Signed in presence of center staff)



PARTICIPANTS MEDICAL HISTORY & PHYSICIANS STATEMENT
Participant: DOB: Height: Weight:
Address:
Diagnosis: Date of Onset:
Past/Prospective Surgeries:
Medications:
Seizure Type: Controlled: Y N Date of Last Seizure:
Shunt Present: Y N Date of last revision:
Special Precautions/Needs:

Mobility: Independent Ambulation Y N Assisted Ambulation Y N Wheelchair Y N
Braces/Assistive Devices:
For those with Down Syndrome: Atlan to Dens Interval X-rays, date: Result: + -
Neurologic Symptoms of Atlan to Axial Instability:
Please indicate current or past special needs in the following systems/areas, including surgeries:
Y N Comments
Auditory
Visual
Tactile Sensation
Speech
Cardiac
Circulatory
Integumentary/Skin
Immunity
Pulmonary
Neurologic
Muscular
Balance
Orthopedic
Allergies
Learning Disability
Cognitive
Emotional/Psychological
Pain
Other
To my knowledge, there is no reason why this person cannot participate in supervised equestrian activities. However, I understand that the
riding center will weigh the medical information above against the existing precautions and contraindications. I concur with a review of this
persons abilities/limitations by a licensed/credentialed health professional (e.g. PT, OT, SLP, Psychologist, etc.) in the implementation of an
effective equine activity program.
Name/Title: MD DP NP PA Other:
Signature: Date:
Address:
Phone: ( ) License/UPIN Number:
MEDICATIONS (include prescription, over-the-counter; name, dose and frequency)





Describe your abilities/difficulties in the following areas (include assistance required or equipment needed):
PHYSICAL FUNCTION (i.e. Mobility skills such as transfers, walking, wheelchair use, driving/bus riding)







PSYCHO/SOCIAL FUNCTION (i.e. 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 Danielle Inman Adaptive Riding of any and all photographs
and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or
for any other use for the benefit of the program.

Date: Consent Signature:
(Client, Parent or Legal Guardian Signed in presence of center staff)