Annual Adaptive Riding Participation Form

Annual Adaptive Riding Participant Application

TROT Policies

Before completing this application, please open and read TROT's updated policy and procedure guide. By submitting this application, you acknowledge and agree to TROT's Terms and Conditions within the updated Policy and Procedure Guide.

READ TROT'S UPDATED POLICY AND PROCEDURE HERE

Policy Agreement

Participant Information

Participant First Name

Participant Last Name

Preferred Name

Address

City

State

Zip

Gender

Race and Ethnicity

DOB

Is the Participant a Veteran/First Responder or a dependent of?

What branch of service?

Are they/you affiliated with the Wounded Warrior Project?

Yes

Personal Health Information

Age

Weight

Height

Primary Diagnosis

Secondary Diagnosis

To safely provide this service, our center requests that you work with your physician to complete/update the Medical History and Physician's Statement Form. Once completed by your physician, please submit to info@TROTarizona.org.

Mobility Status

Communication

Behaviors (Impulsive, fearful, frustration tolerance)

Medications taken

History of Seizures

If 'Yes,' please provide details about the seizures, including frequency, severity, and any known triggers

Precautions/Limitations

Allergies, Asthma, Skin Sensitivity, etc.

Applicant's occupation/school grade level

Personal Goals

Physical Goals (i.e. increase balance, core strength, endurance, flexibility, coordination, accuracy, etc.)

Cognitive Goals (i.e. improve reasoning, problem solving, analytic skills, comprehension, word recognition, precision, demonstration of understanding, social language skills, self-expression, etc.)

Emotional Goals (i.e. improve overall emotional well-being, emotional regulation, accepting NO, recognizing signs of frustration, convey emotional appropriately, etc)

Behavioral Goals (i.e. ability to manage conflict, demonstrate self-regulation, take a break when needed, understanding personal space, easier transitions, etc.)

Contact Information

Primary Contact First Name

Primary Contact Last Name

Relationship to Participant

Preferred Phone

Primary Email

All correspondence will be sent

to the primary email only.

Secondary Contact First Name

Secondary Contact Last Name

Relationship to Participant

Cell Phone

Secondary Email

Medical Emergency Contact Information

In 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.

Emergency Contact is same as Primary Contact

Best Emergency Contact Name

Relationship to Participant

Phone

Preferred Medical Facility

Physician's Name

Health Insurance Company

Policy #

Participant Liability, Confidentiality Agreement, Photo and Video Release

I, the undersigned, understand that there are inherent risks of injury, including death, when participating in an equine activity. Such risks include but are not limited to (1) the propensity of an equine to behave in ways that may result in injury or death to persons on or around them, (2) the unpredictability of an equine’s reaction to such things as sounds, sudden movement and unfamiliar objects, persons or animals, (3) hazards such as surface and sub-surface conditions, (4) collisions with another equine or objects, and (5) the potential negligence of another participant, such as failing to maintain control over the equine or failure to act within the participant’s ability. Knowing and understanding the risks of participating in an equine activity, including injury and death to my person and damage to my personal property, I expressly choose to assume these risks. Further, on behalf of myself, my heirs, successors, representatives, and assigns, I hereby unconditionally release any and all claims and causes of actions against the equine activity sponsor Therapeutic Riding of Tucson (TROT) and its, officers, directors, principals, employees, agents, representatives and any other personnel for injury including death and for any damage to personal property which may incur as a result of my participation in this equine activity. I, the undersigned agree to indemnify the above-described equine activity sponsor (including the above-described persons and entities) from any and all claims and causes of action brought by or on behalf of said participant at any time.

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 of 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.I DO NOT consent to TROT's Photo and video Release

How did you hear about TROT?

We are in the process of updating and streamlining our forms. If you encounter an error message when submitting your application, please take a screenshot of the error and send it to info@trotarizona.org. Thank you for your help!

Contact Information

Annual Adaptive Riding Participant Application

MISSION

CONTACT

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