Heavenly Hooves Program Participant Application

***Note: Enrollment for Fall 2018 is now closed. Please submit applications and paperwork to secure a spot for winter 2019.***

 

***Note: For the safety of our participants and our horses, we must enforce a weight limit for acceptance into this program. There is a weight limit of 200 lbs for ambulatory, balanced riders, and 180 lbs for unbalanced riders (to be determined by the program instructor). If you feel your participant may not meet these requirements, please speak to the program instructor before completing this form.***

 

***Note: All potential participants must have a physician release before they will be evaluated for this program. The release form is found in this registration packet and may also be downloaded from our website.***

All participants will also be required to sign a hard copy of the Health History at evaluation.

Please indicate current or past special needs in the following areas:

Describe your abilities/difficulties in the following areas (include assistance required or equipment needed).

This Health History is up-to-date and accurate, to the best of my knowledge.

All participants will also be required to sign a hard  copy of the photo release at evaluation.

consent to and authorize the use and reproduction by Heavenly Hooves, Inc. (DBA McCormick Research Institute) of any and all photographs and any other audio/visual materials taken of me/my son/my daughter/my ward for promotional printed material, educational activities, or for any other use for the benefit of the program.

All participants will also be required to sign a hardcopy of this form, which will be supplied at evaluation.

 

If emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on Heavenly Hooves' property, I authorize Heavenly Hooves, Inc. 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.

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 below is unable to be reached.

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 McCormick Research Institute. If emergency treatment/aid is required, I wish the following procedures to take place.

Prior to evaluation, every participant must have their physician fill out a Participant's Medical History form. This form can be downloaded from our website or obtained from the program director.

Prior to evaluation every participant must have their physician fill out a Physician's Statement. This form can be downloaded from our website or obtained from the program director.

I understand that I must have the participant's physician sign the Participant's Medical History form and the Physician's Statement prior to evaluation for the Heavenly Hooves program.

About McCormick
 
4651 Rummell Road
St. Cloud, FL 34771
407-933-7433 (RIDE)
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