Participant’s Name  M  F DOB Home Address City State Zip County Home Phone Send all e-mail correspondence to this e-mail: Ethnicity all that apply):  African American  Asian  Hispanic/Latino  Caucasian  Native American  Multiethnic Mother’s Name Mother’s Employer Job Title _______________________________________________ Mother’s Work Phone Mother’s Cell Phone Mother’s Email Father’s Name Father’s Employer Job Title Father’s Work Phone Father’s Cell Phone Father’s Email Participant’s Physician Physician Phone Participant’s Therapist Therapist Phone If you are a new Participant, how did you hear about us:  Physician  Case Manager  School  Friend/Family  Website  Other Current Residence (check one):  Lives w/Family  Foster Home  Nursing Home  Lives Independently Group Home  Individualized Supported Living Specialized Facility If Group Home, provide address and phone: PARTICIPANT PHYSICAL INFORMATION: Height Weight  Verbal  Non-Verbal  Ambulatory  Non-Ambulatory Wheelchair Walker Cane Diagnosis Seizure? Y N Allergies: Medications
PHYSICIAN’S AUTHORIZATION I hereby give medical authorization for (Participant) to participate in the Chakota Therapeutic Riding Center program which includes an evaluation by a physician and/or occupational therapist to assess functional levels and recommend riding exercises. This Authorization does not constitute any medical assurance that the person named above will receive physical or psychological benefits from the program conducted by Chakota Therapeutic Riding Center, nor does it constitute an assessment of the risk of possible injury to said person in relation to the possible psychological or physical benefits from participating in the program. The Participant’s diagnosis is Diagnosis Code PHYSICIAN’S SIGNATURE: Date: If Participant has Downs Syndrome, has ADC (Atlantoaxial Dislocation Syndrome) been ruled out? If ADC is present, do you grant permission for the above named Participant to participate at Chakota Therapeutic Riding Center? YES NO PHYSICIAN’S PRESCRIPTION Please check all that apply. Occupational Therapy Physical Therapy Speech & Language Pathology Participant’s Name Phone Prescription is for evaluation and treatment by a Physical, Occupational, and/or Speech Therapist. Frequency: Precautions: PHYSICIAN’S SIGNATURE: Date: Please type, or stamp: Physician’s Name/Address/Phone RELEASE AND INDEMNITY AGREEMENT (Please be aware this must be signed by Participant or Parent/Guardian.) We, the parents* (guardian) / I (Participant Name) acknowledge that I understand the medical authorization of (Physician) does not constitute any assurance that I will receive physical or psychological benefits from the program conducted by Chakota Therapeutic Riding Center, or does it constitute an assessment of the risk of possible injury to me in relation to the possible physical or psychological benefits from participating in the program. In consideration of the services and the medical authorization of (Physician) I hereby waive, release, and relinquish any and all claims against (him/her) for any and all liability arising from (his/her) authorization for me to participate in the program offered by Chakota Therapeutic Riding Center, and I hereby agree to hold harmless and to indemnify said physician against any and all claims arising from said authorization. Under Illinois Law an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities pursuant to the revised statutes of Illinois Date Signature of Applicant (over 18) Father Mother *In the event that you have sole legal custody of or are the sole living parent of the above named child, only one signature is required.