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Form to be filled out by parent, participant, or legal guardian and returned before first lesson.

 

King’s Stables
Health History Form

Date: February 22, 2020

 

Please select who will be participating...
AdultMinor
Continue
First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

HEALTH HISTORY 


Diagnosis/Disability *

Other therapies currently received *

Current medications *

Psycho-social function (interests, communication issues/style, etc.)

Please mark any of the following that have been a recent or past issue, and provide specific comments where applicable. These items will not be used to prevent anyone from participating; rather, they are to assist us in best meeting your needs:


Mental health therapy

Legal problems

Grief/Loss

Trauma

Special assistance at school

Family problems

Special assistance required 


Sign interpretation

Service dog assistance

Wheelchair assist/transfer

Visual assistance/aids

Emotional/mental helper
Has the student had prior experience with therapeutic riding or hippo-therapy?*
No
Yes

If so, when and where?

Does the student...

Have a history of seizures?*
No
Yes
Follow simple directions?*
No
Yes
Have speech or language difficulties?*
No
Yes
Have communication difficulties?*
No
Yes
Have a fear of animals/horses?*
No
Yes
Walk independently?*
No
Yes
Have limited range of motion?*
No
Yes
Have decreased strength/endurance?*
No
Yes
Have poor balance (sitting/standing)?*
No
Yes
Have problems with gross motor skills?*
No
Yes
Have problems with fine motor skills?*
No
Yes
Have altered sensation? (specify)*
No
Yes
Have heart/circulation problems?*
No
Yes
Have digestion/elimination problems?*
No
Yes
Have bone/joint problems?*
No
Yes
Have allergies or breathing problems?*
No
Yes
Have emotional/behavioral problems?*
No
Yes

Any other important information:
First Participant's Signature*
Parent or Guardian's Email Address

Email
Check to receive information and barn news by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

HEALTH HISTORY 


Diagnosis/Disability *

Other therapies currently received *

Current medications *

Psycho-social function (interests, communication issues/style, etc.)

Please mark any of the following that have been a recent or past issue, and provide specific comments where applicable. These items will not be used to prevent anyone from participating; rather, they are to assist us in best meeting your needs:


Mental health therapy

Legal problems

Grief/Loss

Trauma

Special assistance at school

Family problems

Special assistance required 


Sign interpretation

Service dog assistance

Wheelchair assist/transfer

Visual assistance/aids

Emotional/mental helper
Has the student had prior experience with therapeutic riding or hippo-therapy?*
No
Yes

If so, when and where?

Does the student...

Have a history of seizures?*
No
Yes
Follow simple directions?*
No
Yes
Have speech or language difficulties?*
No
Yes
Have communication difficulties?*
No
Yes
Have a fear of animals/horses?*
No
Yes
Walk independently?*
No
Yes
Have limited range of motion?*
No
Yes
Have decreased strength/endurance?*
No
Yes
Have poor balance (sitting/standing)?*
No
Yes
Have problems with gross motor skills?*
No
Yes
Have problems with fine motor skills?*
No
Yes
Have altered sensation? (specify)*
No
Yes
Have heart/circulation problems?*
No
Yes
Have digestion/elimination problems?*
No
Yes
Have bone/joint problems?*
No
Yes
Have allergies or breathing problems?*
No
Yes
Have emotional/behavioral problems?*
No
Yes

Any other important information:
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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