Dear Rider, Thank you for your interest in The Root Farm’s equine related programming. Our staff is looking forward to providing a safe and productive lesson each week as we work towards achieving individual goals. Listed below you will find an overview of our lesson fees, registration requirements and other information that you will need to know before starting the program. Please note that The Root Farm offers a variety of programming options, including, hippotherapy, adaptive English, Western and Vaulting, non-adaptive lessons and recreational programming. Rates (lessons are scheduled in six week blocks): o Initial consultation/evaluation (new riders only*) – $40 * New riders are defined as riders that have never participated in Root Farm equine programs, or, have not participated in Root Farm equine programs in over a year. o Group lesson (3-4 riders) – $240 for a six-week block ($40 per lesson) o Semi-Private hippotherapy session (2 riders) – $270 for a six-week block ($45 per session) o Private ½ hour lesson – $50 per lesson o Private one-hour session – $100 per session All participants must complete the accompanying Application, Medical and Liability Release Form and Cancellation/Refund Policy. The Patient Medical History and Physician Statement Form must be signed by a physician and returned prior to starting lessons. Riders participating in hippotherapy must also obtain and submit a script for therapy services. Weight Policy - For the safety of our horses, rider weight is generally limited to 200 pounds. If a rider is over 180 pounds they must be able to transfer on and off a horse independently. Decisions regarding participation will be based on availability of a suitable horse relative to the height, cognition and balance of the participant. If you have your own helmet, it must have a manufacture date within the last five years and meet national ASTM/SEI safety standards. Helmets older than 5 years old cannot be used. Please check with a Root Farm Instructor for approval. Wearing proper attire is necessary for correct, effective and safe riding. Closed toed shoes must be worn at all times. Our staff will review attire and other safety policies prior to your first lesson. Completed applications can be emailed to firstname.lastname@example.org or mailed to: The Root Farm 2860 King Road Sauquoit, NY 13456 If you have any questions, please feel free to call us at (315) 520-7046. We look forward to having you ride with us at The Root Farm. Sincerely, Peter Blanchfield Executive Director The Root Farm
NEW RIDER APPLICATION RIDER INFORMATION DOB: / / Age: Name: Address: Phone: Email: Parent/Legal Guardian: Address: Phone: Medicaid Eligible: Yes Email: _ No Insurance Provider: _______________________________ General Medical Information Diagnosis: Allergies: Height: Weight: Current Medications Name: ___________________________ For Treatment Of:__________________________ Name: ___________________________ For Treatment Of:__________________________ Name: ___________________________ For Treatment Of:__________________________ Physician’s Name: Physician’s Phone: Date of Last Physical Exam: Examined by: Describe any medical conditions requiring special precautions or treatment (including but not limited to dietary restrictions and any past seizure activity): EMERGENCY CONTACTS (Please list at least 2 in the order they should be contacted) Phone: Name: Relation: Signature of the person completing this form Relation to the Rider Date
PLEASE PROVIDE US WITH THE FOLLOWING RIDER INFORMATION SO WE CAN BETTER SERVE YOU: Rider Name Date What do you hope to achieve through your participation in the services offered by The Root Farm? Have you ever participated in horseback riding before? If so, when and where?What are your interests, hobbies, favored activities? What activities or things do you avoid or dislike? Do you have any toileting concerns? If so, please explain. What are your self-care needs, if any? Describe any sensory issues you think we should be aware of (ie: loud noises, touch, movements, etc.) Please describe any behavioral issues that may come up during equine related activities,what triggers them, and some effective ways to address them. (ie: aggressive behaviors, loud outbursts, sudden movements or fleeing, etc.) What else would you like us to know so that we can provide you with a fun, safe, positive experience at The Root Farm? Signature of the person completing this form Relation to the Rider Date
Medical and Liability Release Riding instruction and therapy will be under strict supervision, and although every effort will be made to avoid any accident, no liability can be accepted by The Root Farm. Rider’s Name In case of medical emergency, the undersigned authorizes The Root Farm to seek medical assistance as they determine necessary. The undersigned also authorizes any licensed physician and/or medical facility to provide any medical/surgical care and or hospitalization for the rider, which they have determined necessary and/or advisable, pending receipt of this consent form. In agreement with the above mentioned requirements, I would like to participate in equine related and/or physical therapy activities at The Root Farm. I have discussed this with the rider’s physician. I understand that The Root farm is not liable for any injury or health related concerns that may result from participating these equine-related activities. No person can be accepted into the riding program until this form has been completed by the parent or guardian. If the person is of legal age (18), he/she may complete the form if he/she is legally competent to do so. Date Signature of Parent/Guardian Date Signature of Rider if over 18 years old
PHYSICAL THERAPY INFORMATION DATE: NAME: D.O.B.: MEDICAL HISTORY: ADAPTIVE EQUIPMENT: CURRENT THERAPIES: Physical Therapist Weekly Frequency Contact Information Occupational Therapist Weekly Frequency Contact Information Speech Therapy Weekly Frequency Contact Information GOALS (what gross motor/daily life skills do you want to improve?): 1. 2. 3. COMPLETED BY RELATIONSHIP TO RIDER PHONE:
Photography/Videotape/Information Release We respectfully request permission to gather, use or disseminate a photograph, audio tape, video tape, or information about yourself or the participant for whom you are responsible (whichever appropriate). Through this release, I hereby give my consent and authorize Upstate Cerebral Palsy, Cerebral Palsy Association, Mohawk Valley Handicapped Services or The Root Farm to take, use and disseminate photographs and/or videotapes and/or audio tapes, or to release appropriate information about (Print Name of Person): for use by the news media or for Agency community relations, publications, or other program-related purposes according to the following guidelines: PHOTO/VIDEO/INFORMATION USAGE GUIDELINES Photo/Video/Information are to be used for the following purposes (please check all boxes that apply): Photo/ Video/ Information is for 1-time use only (please indicate) Photo/ Video/ Information can be used only when specific event is being publicized (name event below) Photo/ Video/ Information can be used for any agency purposes Relating to The Root Farm - to be used in agency brochures, on website, promotional materials, etc. I do not give my permission for any media exposure Signature: Client/Participant/Volunteer Date Printed Name of Above Person Signature of Parent/Guardian/Person Responsible for Participant (If required) Date Printed Name of Responsible Person (If required) Signature of Witness or Employee Date Printed Name of Above Person If you have any questions, please feel free to contact the Community Development Of fice, at 724-6907, ext. 2302.
Dear Health Care Provider: Your patient is interested in participating in either adaptive horseback riding lessons, OR physical therapy that incorporates equine movement as one of many treatment strategies to improve functional outcomes. The Root Farm riding lessons and physical therapy involve both mounted and ground activities. Please consider the following conditions when completing this medical clearance form. The following conditions ARE contraindicated for therapeutic riding: •Structural scoliosis greater than 30 degrees •Uncontrolled seizures •Positive X-Ray for Atlantoaxial Instability •Tethered Cord •Hip subluxation, dislocation, or degeneration •Indwelling catheter •Spinal Cord Injury above a T-6 •Hemophilia •Chiari II Malformation The following conditions MAY BE Contraindicated: •Osteoporosis •Osteogenesis Imperfecta, lordosis, or kyphosis •Recent Surgeries •Recurrent pathological fractures •Spina Bifida •Spinal fusions/ spinal instability /spinal stabilization devices •Varicose veins •Diabetes If you have any concerns or questions, please don't hesitate to call us at 315-520-7046. Sincerely, The Root Farm Staff
ANNUAL MEDICAL HISTORY and PHYSICIAN’S STATEMENT Participant’s Information Participant’s Name: Today’s Date: Address: ____ ____ DOB: Gender: M F Medical Summary Primary diagnosis: Cause if known: Other diagnoses: If Down Syndrome - result of test for AAI: _____ Negative _____ Positive Date of Test: Recent surgical procedures or hospitalization: Date of last tetanus: _______________________________ Precautions/Contraindications ( Please check all that currently apply to your patient and degree of involvement, or note history in space provided. Please note that the following conditions may be contraindicative to horseback riding): Allergies (specify type) ____ Arthritis (rheumatoid or osteo) Asthma ____ Atlanto-Axial Instability-positive X-ray or positive neurological exam _______________________________________ ____ Behaviors _____________________________________________________________________________________ ____ Blood Clots, deep vein thrombosis, peripheral vascular disease __________________________________________ ____ Body Temperature regulation problems ______________________________________________________________ ____ Bone Abnormalities _____________________________________________________________________________ ____ Brain Injury ____________________________________________________________________________________ ____ Communicable Diseases _________________________________________________________________________ ____ Contractures/ limited ROM (location) ________________________________________________________________ ____ Gastro-intestinal or naso-gastric, or tracheal tube ______________________________________________________ ____ Heart condition/ abnormality _______________________________________________________________________ ____ Hypertension ___________________________________________________________________________________ ___ Joint/ tendon laxity, sublaxation, dislocation ___________________________________________________________ ____ In-dwelling catheter ______________________________________________________________________________ ____ Shunt _________________________________________________________________________________________ ____ Psychiatric condition (type) _________________________________________________________________________ ____ Respiratory complications (type) ____________________________________________________________________ ____ Seizures (list type, frequency and duration) ___________________________________________________________ ____ Skin integrity issues, skin breakdown, skin/decubitus ____________________________________________________ ____ Chiari II malformation, tethered cord (include release date) ________________________________________________ ____ Scoliosis _______________________________________________________________________________________ ____ Spinal fusion or internal fixators (specify area, type, vertebrae involved) ______________________________________ ____ Spinal Instability __________________________________________________________________________________ ____ Other (Please Specify) _____________________________________________________________________________ Physician’s Statement In my capacity as medical advisor, I consent to the participation of in the adaptive horseman/recreational horseback riding program and/or therapy services at The Root Farm. I certify that all of the information that I have given is accurate and represents a complete medical history. (Patient’s full name) Physician’s name: Address or stamp: Date:
Cancellation and Refund Policy Our goal is to provide quality programming in a timely manner. "No-shows" and late cancellations prevent us from providing programming to all interested individuals. In order to do so, we ask that youread and sign our policy regarding missed appointments and refunds. This policy enables us to betterutilize available appointments for you and all participants. Payment Policy Payments must be made before participation in your scheduled appointment. If payments are not received by the end ofyour first appointment time, The Root Farm reserves the right to offer your future appointments to a rideron our extensive waiting list. Please note that our rates are subject to change. Cancellation of an Appointment In order to be respectful of the needs of other program participants, please be courteous and call TheRoot Farm promptly if you are unable to participate in a scheduled session. With prior notification ofyour cancellation, of at least 24 hours, you will not be charged for the missed session, and will have an opportunity to make up the missed session free of charge. In addition, you will be giving a rider on the waiting list an opportunity to fill that empty slot. Any “noshow” or cancellation that is made without at least 24 hours noticed, cannot be made up, and will result in a charge for that missed session. Refund Policy Refunds will not be given for any sessions that have been already been provided. If it becomes necessary to leave the program when you have not completed a full block of sessions, we require that you notify us of this intent, at least 72 hours in advance of your next scheduled session. Inthe event that a program participant is unable to continue, a refund will be made to the participant for anyunused sessions at an amount of $30 per session. Failure to notify the program in a timely manner willrequire you to pay any outstanding fees. How to Cancel Your Appointment To cancel your riding session, please call 315-520-7046 ext. 221. If no one answers, you may leave a detailedmessage on the voicemail which will be considered notification of your need to cancel your scheduledsession or sessions. We will return your call as soon as we are available. Weather Related Changes or Cancellations Every effort will be made to hold scheduled sessions. It may, however, become necessary for TheRoot Farm to cancel sessions due to inclement weather including extreme heat, cold, poor weather, etc. In such situations, a member of our staff will call the number you have on file to notify you that yourscheduled session has been cancelled. If no one answers, a voicemail will be left notifying you of that thesession has been cancelled. Sessions cancelled by program staff, due to inclement weather, will not countagainst your total number of paid sessions. Instead, a make-up session will be scheduled at no additionalcharge. The Root Farm Staff reserve the right to modify a session from riding programming, to ground based activities, in the event of a weather related event that does not require a cancellation and/or for the safety of the rider and/or staff. If timing allows, a member of our staff will call the number you have on file to notify you of such a change in programming and give you an option of participating. If timing does not allow for prior notification, the change in programming will be made for the safety of all involved and the session will be counted as a normal riding program session.
ACKNOWLEDGEMENT OF THE ROOT FARM CANCELLATION AND REFUND POLICY I, have read,understand, and agree to the cancellation and refund policy for The RootFarm. Date Participants Name Signature of Person Acknowledging Policies Relationship to Participant