Group Participant Information Form (Riding)
PARTICIPANT & PARENT INFORMATION
Participant First Name
Participant Last Name
Date of Birth
What school or group are you attending with?
Parent/Guardian First Name
Parent/Guardian Last Name
Is this person the participant's emergency contact?
Yes
No
Address
Address Line 1
Address Line 2
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
MH
GU
MP
PR
VI
Zip Code
Cell Phone
Email
EMERGENCY CONTACT INFORMATION
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Phone
Relationship to Participant
Participant Demographic Information
Thank you for taking the time to provide the following information. This section is designed to help us better understand the diverse community we serve and to ensure that we are effectively meeting the needs of all our participants. The data collected will be used solely to improve our services and programming. Rest assured, all personal information provided will be kept strictly confidential and will not be shared with any external parties.
Gender:
Male
Female
Non-binary
Prefer not to say
Please describe
Race/Ethnicity (select all that apply):
African American/Black
Asian
Caucasian/White
Hispanic/Latino
Native American/Alaska Native
Native Hawaiian/Pacific Islander
Prefer not to say
Please describe
Primary Language Spoken at Home:
English
Spanish
Russian
Korean
Other
Please describe
Household Income for participant:
Less than $25,000
$25,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
$150,000 or more
Prefer not to say
Education Level of participant:
Less than high school
High school diploma or equivalent
Some college, no degree
Associate degree
Bachelor’s degree
Graduate or professional degree
Prefer not to say
Employment Status of participant:
Employed Full-Time
Employed Part-Time
Unemployed
Student
Retired
Prefer not to say
Current Living Situation:
Own Home
Rented Home
Group Home
Senior Housing
Supportive Housing
Sheltered/Unhoused
Please describe
Transportation Method to Our Facility (select all that apply):
Drive Self
Ride from Family/Caretaker
Public Transportation
Rideshare Service (Uber, Lyft, etc.)
Carpool
Walking
Biking
Please describe
PARTICIPANT DETAILS
Height
Weight
Communication
Please select...
Verbal
Nonverbal
Assistive Device
Other
Please describe:
Ambulation
Please select...
Walks Independently
Walks with Assistance
Does Not Walk
Other
Please describe other ambulatory needs:
What medications is the participant currently taking, including over-the-counter medications?
Please describe the participant’s functional abilities (i.e. mobility skills such as transfers, walking, wheelchair use, driving/bus riding).
Please describe the participant’s social structure/interests (i.e. Work/school including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc.).
Does the participant have any food allergies?
Does the participant have any diagnoses or history of medical conditions? If so, please search for/select them in the box(es) below.
Select diagnosis or medical condition below
Please describe details about the diagnoses/history of medical conditions:
What goals would you like the participant to accomplish?
LIABILITY RELEASE
Participant First Name
Participant Last Name
I acknowledge the risks and potential for risks of horseback riding. However, I feel that the possible benefits to my self, my son, my daughter, my ward are greater than the risk assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against Pony Power Therapies, Inc., its Board of directors, instructors, therapists, volunteers and/or employees for any and all injuries and/or losses I may sustain while participating in Pony Power Therapies, Inc. By checking above, I agree to the terms.
Yes
I consent to and authorize the use and reproduction by Pony Power Therapies of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
I do
I do not
Parent/Guardian First Name
Parent/Guardian Last Name
Date