New Participant Application - 5/22/2020 Program InformationDate* MM slash DD slash YYYY Participant Name* First Last Phone*DOB* MM slash DD slash YYYY Age*Please enter a number from 4 to 99.Height* Weight* Gender* Male Female Race and Ethnicity*American Indian or Alaskan NativeAsianBlack or African AmericanCaucasianHispanicNative Hawaiian or Other Pacific IslanderOtherPrefer not to disclosePrimary Diagnosis* Secondary Diagnosis Veteran No Yes If yes, what branch of service? If yes, are you affiliated with the Wounded Warrior Project? No Yes Mobility status (walks unassisted, assistive devices, etc.) Communication (verbal, non-verbal, signs) Behaviors (impulsive, fearful, frustration tolerance) Medications taken Seizures (if applicable please describe) Limitations Allergies, Asthma, etc. Skin sensitivity Participant’s occupation/ school grade level Personal Goals Other Availibility for the TROT Program(Please check all that apply)Morning Classes 8:00 am to 10:45 am* Monday AM Tuesday AM Wednesday AM Thursday AM Friday AM Saturday AM None Afternoon Classes 4:00 pm to 6:30 pm* Monday PM Tuesday PM Wednesday PM Thursday PM Friday PM None *How did you hear about TROT? Internet Word of Mouth PT/OT Primary Care Physician Referred by: Participant Contact and Tuition InformationParticipant Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhoneApplicant Email* Guardian (1) First Last Relationship Cell PhoneWork PhoneEmail Guardian (2) First Last Relationship Cell PhoneWork PhoneEmail Medical Emergency Contact InformationIn 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.Best Emergency Contact Name* First Last Phone*Relationship to Participant* Other Phone #Preferred Medical Facility: Physicians Name: First Last Health Insurance Company: Policy # Program Tuition Payment Details$45 One Time Assessment FeePlease tell us how you will be paying:* Check (please make payable to TROT) Credit Card (please call TROT at (520) 749-2360 x600 to pay by credit card) I understand and agree that all paperwork must be up to date. All tuition is to be paid prior to the start of each semester or on the first day of class in full ($540) or in three (3) monthly installments of ($180). If applicable, all scholarship forms must accompany the rider application.Date* MM slash DD slash YYYY Participant or Legal Guardian* First Last Tuition Payment Consent* I understand and agree to TROT's Tuition Payment policy.Participant Liability, Confidentiality Agreement, Photo and Video ReleaseLiability 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 Directors, Instructors, Therapists, Aids, Volunteers and Employees for any 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 in allowing me/my child/my ward to participate in activities at TROT. Liability Release Consent* I agree to the TROT Liability Release Agreement.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 or their parent/guardian if a minor. Confidentiality Agreement Consent* I agree to the TROT Confidentiality Agreement.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: Agreement I DO NOT consent to TROT's Photo and Video Release: Agreement
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