Group participant information form (riding) Group Participant Information Form (Riding) PARTICIPANT & PARENT INFORMATION Participant First Name Participant Last Name Date of Birth What school or group are you attending with? Parent/Guardian First Name Parent/Guardian Last Name Is this person the participant's emergency contact?YesNo Address Address Line 1 Address Line 2 City StatePlease select... AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY MH GU MP PR VI Zip Code Cell Phone Email EMERGENCY CONTACT INFORMATION Emergency Contact First Name Emergency Contact Last Name Emergency Contact Phone Relationship to Participant Participant Demographic Information Thank you for taking the time to provide the following information. This section is designed to help us better understand the diverse community we serve and to ensure that we are effectively meeting the needs of all our participants. The data collected will be used solely to improve our services and programming. Rest assured, all personal information provided will be kept strictly confidential and will not be shared with any external parties. Gender:MaleFemaleNon-binaryPrefer not to sayOther Please describe Race/Ethnicity (select all that apply):African American/BlackAsianCaucasian/WhiteHispanic/LatinoNative American/Alaska NativeNative Hawaiian/Pacific IslanderPrefer not to sayOther Please describe Primary Language Spoken at Home:EnglishSpanishOther Please describe Household Income for participant:Less than $25,000Less than $25,000$50,000 - $74,999$75,000 - $99,999$100,000 - $149,999$150,000 or morePrefer not to say Education Level of participant:Less than high schoolHigh school diploma or equivalentSome college, no degreeAssociate degreeBachelor’s degreeGraduate or professional degreePrefer not to say Employment Status of participant:Employed Full-TimeEmployed Part-TimeUnemployedStudentRetiredPrefer not to say Current Living Situation:Own HomeRented HomeGroup HomeSenior HousingSupportive HousingSheltered/UnhousedOther Please describe Transportation Method to Our Facility (select all that apply):Drive SelfRide from Family/CaretakerPublic TransportationRideshare Service (Uber, Lyft, etc.)CarpoolWalkingBikingOther Please describe PARTICIPANT DETAILS Height Weight CommunicationPlease select... Verbal Nonverbal Assistive Device Other Please describe: AmbulationPlease select... Walks Independently Walks with Assistance Does Not Walk Other Please describe other ambulatory needs: What medications is the participant currently taking, including over-the-counter medications? Please describe the participant’s functional abilities (i.e. mobility skills such as transfers, walking, wheelchair use, driving/bus riding). Please describe the participant’s social structure/interests (i.e. Work/school including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc.). Does the participant have any food allergies? Does the participant have any diagnoses or history of medical conditions? If so, please search for/select them in the box(es) below. Select diagnosis or medical condition below Please describe details about the diagnoses/history of medical conditions: What goals would you like the participant to accomplish? LIABILITY RELEASE Participant First Name Participant Last Name I acknowledge the risks and potential for risks of horseback riding. However, I feel that the possible benefits to my self, my son, my daughter, my ward are greater than the risk assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against Pony Power Therapies, Inc., its Board of directors, instructors, therapists, volunteers and/or employees for any and all injuries and/or losses I may sustain while participating in Pony Power Therapies, Inc. By checking above, I agree to the terms.Yes I consent to and authorize the use and reproduction by Pony Power Therapies 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.I doI do not Parent/Guardian First Name Parent/Guardian Last Name Date
