WELCOME TO PTR PAPERWORK Please initial All forms must be completed and signed prior to the first ride or session. The Medical Release form needs to be submitted with an original signature, no copies or faxes. Please note that participants cannot ride without this completed form submitted to PTR, on or before the first ride. NO EXCEPTIONS SCHEDULING Scheduling is on a first come-first serve basis. We try to group our riders by similar skill level and age. Riders participate at a minimum of one ride per week for a six week ride session. NEW PARTICIPANTS First step is an intake evaluation and tour of our facility. There is a $35 fee for the appointment that will be applied to the first ride should the rider sign up for a six week session. A completed application is required for the evaluation appointment. RIDE TIMES You will be given a specific ride time. Please arrive at least 15 minutes before your scheduled ride. There is a comfortable waiting area. LATE ARRIVALS: 15 minutes past your designated ride time, your horse and volunteers will NOT be available in order for us to stay on schedule for the next rider. You can be mounted up to 10 minutes late, but your ride will be shortened. No credit will be issued. PAYMENT PROCEDURES We accept cash or check. Fees must be paid prior to or on the first ride of the session. A fee equal to the bank charge will be assessed for returned checks. Class Fee for 30 minute Therapeutic Riding is $175 for a six week prepaid session OR $35 per ride. Private Therapeutic Riding Lesson - $45 per 30 minute lesson Private Equine Driving Lesson - $50 per 50 minute lesson CANCELLATIONS We understand things happen that are out of our control from time to time. A 24 hour notice is required to achieve a ride credit. A no-show will receive no credit. A rider who misses more than 3 rides will be re-evaluated for continued service. Please realize we have a horse and up to 3 volunteers scheduled and waiting for your rider so calling ahead to cancel prevents wasted time. ACCESS TO PROPERTY Please note that the facility is a private residence. Consequently, access to the property is by appointment only or for your designated ride time. Please do not disturb the residents. Enter through the designated gate. Also note that horses are not to be approached. INFECTIOUS DISEASES Please be considerate or all our riders, volunteers and staff members. Stay home if there is a chance of spreading something contagious. Call at the first sign of an illness, not just before class. WEATHER Weather is unpredictable in Arizona, especially rain and lightning. PTR reserves the right to cancel classes, before or even during class, if the instructor deems the situation unsafe for riders, volunteers or horses. We will make every effort to contact riders about cancellations beforehand but sometimes the decision to cancel can occur when the rider has already left home. We ask for your understanding. A credit will be issued for weather related cancellations. HELMETS ARE REQUIRED Riders must provide their own ASTM/SEI helmets. These can be purchased at any equine store (i.e. Tack Etc or Greenway Saddlery). Bicycle helmets are not acceptable. DRESS CODE Appropriate attire is essential for the comfort and safety of the rider. Long pants are required; belts are helpful. Please avoid all slippery fabrics and bulky clothing including jackets. Footwear with heels are best for riding (no sandals no exceptions). A rider is subject to missing his/her ride if not properly dressed. Please have your rider prepared for hot Arizona summers and cold winters. Close fitting fingered gloves are ok. WEIGHT RESTRICTIONS FOR RIDING Horses are selected based on the rider s skill set, rider weight, horse conformation and movement. To insure the safety and comfort of our equine partners, we have to establish weight limits for our rides. It is 200 pounds for a balanced rider and 185 for an unbalanced rider. Horses that can carry the heavier weights are limited and available on a first come, first serve basis. PARKING Parking is available along the east wall of the property. Please drive slowly and do not block the alleyway leading to the entry gate OBSERVING CLASSES We have a patio area for observing classes. Please wait on the patio until the rider is called and for the remainder of their class. The barn and horse prep area is strictly off limits unless an escort is available. We invite you to bring family members and friends as long as there is no disruption of classes. Noisy activities or play can distract riders and horses. This is for the safety of the rider, volunteers and especially the horses that could spook. We also want to preserve the integrity of the class. Thank you for your cooperation SMOKING Absolutely NO smoking is allowed on the property unless you want to smoke in your car. -Welcome II 10/12 Page 1
ARIZONA EQUINE ACTIVITY STATUTE (Please read carefully) A.R.S. s 12-553: It is recognized that equestrian activities are hazardous to participants, regardless of all feasible safety measures which can be taken. Each participant in an equestrian activity expressly assumes the risk of and legal responsibility for any injury, loss or damage to person or property which results from participation in an equestrian activity, on or around a horse. Footnote: Although every effort is made to provide safe, specially trained equine partners, the rider and family understand that horses are by nature unpredictable and therefore assume any and all liability for any injury to the participant. I/We understand the information address on this form and agree to the above conditions outlined by Paradise Therapeutic Riding, LLC. Signature of Rider or Parent/Guardian (if under age 18) Printed name of Rider or Parent/Guardian -Welcome II 10/12 Page 2
RIDER APPLICATION RIDE YEAR 2012-2013 (MUST be filled in completely in Blue or Black Ink ONLY) NAME: DATE COMPLETED: ADDRESS: HOME PHONE: ( ) CITY/STATE: ZIP: ALT. PHONE: ( ) BIRTH DATE: AGE: HEIGHT: WEIGHT: Male/Female DISABILITY (primary & secondary): SEIZURES: YES NO CONTROLLED DATE OF LAST SEIZURE: MEDICATIONS: AMBULATION (Wheelchair, canes, etc.): PARENT/GUARDIAN: E-Mail: OCCUPATION/PLACE OF EMPLOYMENT: SIBLINGS (NAME & AGE): DOCTOR S NAMES/ADDRESSES/PHONE: THERAPIST S NAMES/ADDRESSES/PHONE: Would you provide a copy of any current therapy reports? YES NO Is your therapist willing to interact with our program? YES NO SCHOOL/EDUCATION/DAY PROGRAM: PHYSICAL LIMITATIONS: POSITIVE REINFORCERS: ATTENTION SPAN: SITTING POSTURE: VISUAL: SPEECH: Please answer the following questions (use the back if needed): HEARING: PROSTHESIS: 1. Have there been any significant changes in the rider s condition within the past 3 to 6 months? Please let us know of any changes in health or physical development. 2. How did you hear about us? 3. Please indicate any special billing information. 4. Is there anything that we should know about the rider? 5. What are your expectations of our therapeutic riding program? -RIDER APPLICATION 10/12 Page 3
RIDER NAME: (Please Print) PHONE NUMBER: AREA CODE: ( ) RELEASE AND HOLD HARMLESS AGREEMENT Under Arizona Law, an Equine Activity Sponsor or Equine Professional is not liable for an injury to or the death of a participant or volunteer in equine activities resulting from the inherent risks of equine activities. The Undersigned Participant, volunteer or Undersigned Parent/Guardian of the Participant or volunteer assumes the unavoidable risks inherent in all horse-related activities, including but not limited to bodily injury, physical harm, loss, damage or death to the Participant, spectators, family members, guests and any horses owned by the Undersigned. The Undersigned hereby releases, waives, covenants not to sue for any of the above. In consideration, therefore, for the privilege of riding, observing, working with and/or engaging in Equine Coaching or Equine Facilitated Learning related activities or therapeutic riding/driving with the horses and other animals with Exploitation and Abuse Recovery Services LLC, Lisa Péwé, Leslie Paradise, Paradise Therapeutic Riding, LLC, and any additional volunteers, the Undersigned does hereby agree to hold harmless and indemnify against all claims, Exploitation and Abuse Recovery Services LLC, Lisa Péwé, Leslie Paradise, Paradise Therapeutic Riding, LLC, property owners and horse owners and any other facilitators, or instructors or apprentices, or volunteers and any and all Heirs and Assigns (the Indemnified Parties) and further releases from any liability or responsibility for accident, damage, injury, or illness to the Undersigned Participant and/or Parent/Guardian of the Participant, or to any family member or spectator accompanying the Participants on the premises or around the horses owned or leased by Exploitation and Abuse Recovery Services LLC, Lisa Péwé,Leslie Paradise, Paradise Therapeutic Riding, LLC, and property owners at any location that might be utilized by Exploitation and Abuse Recovery Services LLC, Lisa Péwé, Leslie Paradise, Paradise Therapeutic Riding. Print Name of Participant Age (If under 18) Phone Number Signature Participant/ Parent/Guardian Check one: Participant Parent/Guardian of Participant/Volunteer Print Name of Parent/Guardian of Participant Phone Number Print Complete Address of Participant (include street, city, state, country, zip code) Print Name of Emergency Contact of Participant /Volunteer Phone Number AUTHORIZATION FOR EMERGENCY CARE I hereby authorize Exploitation and Abuse Recovery Services LLC, Lisa Péwé, Leslie Paradise, Paradise Therapeutic Riding, LLC, their agents, independent contractors volunteers and employees to obtain emergency medical care me or my child if, in their opinion at the time it is needed, such care being at our sole expense. Signature of Participant/Parent/Guardian (if necessary) RIDERS: I represent that I am physically able to undertake riding activities and have presented a Physician s Medical Statement indicating approval of my participation and I do so at my own risk. INITIALS: RIDER Liability 10/12 Page 4
RIDER PHOTO RELEASE I hereby consent to and authorize the use and reproduction by this Facility of any and all photographs and any other audiovisual materials taken of me/my son/my daughter/my ward, for promotional printed material, educational activities, exhibitions or for any other use for the benefit of the program. Signature of Rider, Parent, or Guardian RISK MANAGEMENT STATEMENTS I understand that I cannot smoke while on the property unless in this designated area: I understand there are specific business hours at which time staff are present on property. Visiting at other times is not encouraged. I understand that I must wear an approved ASTM approved riding helmet to ride any horse. Y Y Y N N N I understand that horses are to be visited only with an escort and are not to be fed anything by hand. (Hand feeding encourages biting and nipping). Y N I understand that horses are unpredictable. They may kick, bite, and step on me. Y N Signature of Rider, Parent or Guardian CONFIDENTIALITY STATEMENT Volunteers, riders and their families have a right to privacy that gives them control over the dissemination of their medical and/or other sensitive information. This Facility shall preserve that right of confidentiality for all individuals in its program. I, by signing below, acknowledge this policy and will abide by it. Signature of Rider, or Parent/Guardian P.O. Box 30921 Email: paradisetriding@gmail.com Phone 602-971-1659 Fax 602-765-1606 Phoenix, AZ 85046 Website: http://www.horsesandtherapy.com RIDER Risk/Conf/Photo 10/12 Page 5
Leslie W. Paradise, CTRI, CTDI P.O. Box 30921, Phoenix, AZ 85024 Telephone: (602) 971-1659 Email: paradisetriding@gmail.com Fax: 602-765-1606 Dear Physician: Your patient would like to participate in our therapeutic riding program. These activities are supervised by riding instructors who are certified by PATH International, (Professional Association of Therapeutic Horsemanship) and assisted by volunteers. Because safety is of the utmost importance, we request your evaluation of this person s appropriateness for horseback riding with us. The following are some of the precautions/contraindications that we take into account when considering riders for our programs. We welcome your comments, questions and concerns. All of our riders must have an original current signed and dated medical release on file with us in order to participate (see reverse side for form). ORTHOPEDIC Atlantoaxial instability include neurologic symptoms Coxa arthrosis Cranial deficits Heterotopic ossification/myositis ossificans Joint subluxation/dislocation Osteoporosis Pathologic fractures Spinal fusion/fixation Spinal instability/abnormalities NEUROLOGIC Hydrocephalus/shunt Seizure Spina Bifida/Chiari II malformation/tethered Cord/hydromyelia OTHER Age under 4 years Indwelling catheters Medications i.e. photosensitivity Poor endurance Skin breakdown MEDICAL/PSYCHOLOGICAL Allergies Animal abuse Physical/sexual/emotional abuse Blood pressure control Dangerous to self or others Exacerbation of medical conditions Fire setting Heart conditions Hemophilia Medical instability Migraines PVD Respiratory compromise Recent surgeries Substance abuse Thought control disorders Weight control disorder To discuss activities or benefits associated with equine-assisted therapeutic activities, or receive additional references or information, please call us at (602) 971-1659. We appreciate your assistance. Please complete and return this form to: Leslie W. Paradise, CTRI, CTDI Paradise Therapeutic Riding, LLC P.O. Box 30921 Phoenix, Arizona 85024
Leslie W. Paradise, CTRI, CTDI P.O. Box 30921, Phoenix, AZ 85024 Telephone: (602) 971-1659 Email: paradisetriding@gmail.com Fax: 602-765-1606