Participant’s Application & Health History

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Participant’s Application & Health History

Email *

GENERAL INFORMATION

Participant’s full name

DOB

YYYY

Age

Height

Weight

Gender

Clear selection

Address

Phone

Alternative #

Employer/School

Employer/School Address

Employer/School Phone

Parent/Legal Guardian

Caregivers

Address (if different from above)

Phone

Referral Source/How did you hear about the program

HEALTH HISTORY

Diagnosis

Date of Onset

YYYY

Allergies

Physician's Name

Preferred Medical Facility

Health Insurance Company

Policy #

In Case of EMERGENCY

Include 2 emergency contacts: Contact Name | Relationship | Phone

Medical Release *

In the event emergency medical aid/treatment is required due to illness or injury while present on the property of Horse Life Miami, check one [ ⃝ I authorize] [ ⃝ I do not authorize] Horse Life Miami to secure transportation to the nearest hospital. The undersigned hereby agrees to pay all fees and expenses of doctors, hospitals, ambulances and other medical expenses incurred.

I Authorize

I Do Not Authorize

I have read and made a selection for emergency medical as indicated above:

Name (Parent or Guardian if Minor)

Date

YYYY

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

YES

Comments

Vision

Hearing

Sensation

Communication

Heart

Breathing

Digestion

Elimination

Circulation

Emotional/Mental Health

Behavioral

Pain

Bone/Joint

Muscular

Thinking/Cognition

Describe Comments here:

MEDICATIONS

include prescription and over-the-counter, name, dose and frequency

Describe your abilities/difficulties in the following areas

(include assistance required or equipment needed):

PHYSICAL FUNCTION

(e.g., mobility skills such as transfers, walking, wheelchair use, driving/bus riding)

PSYCHOSOCIAL FUNCTION

(e.g., work/school including grade completed, leisure interests, support systems, companion animals, fears/concerns, etc).

GOALS

(i.e., why are you applying for participation? What would you like to accomplish?)

ACCEPTANCE *

Name and Date

PHOTO RELEASE *

I consent to and authorize the use and reproduction by Horse Life Miami 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.

Do Not

SIGNATURE *

Name of Client, Parent or Legal Guardian and Date

Send me a copy of my responses.

Submit

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