LifeStriders

Phone: 262.309.9297
Fax: 866.404.3105
striders@lifestriders.org

Sll W29667 Summit Avenue (US HWY 18)
Waukesha, WI 53188

Therapeutic Riding Form

Participant's Application


Male Female

No Yes

Participant's Health History

Please Indicate Current or Past Problems in the Following Areas:
Yes Comments
Vision
Hearing
Sensation
Communication
Heart
Breathing
Digestion
Elimination
Circulation
Emotional
Behavioral
Pain
Bone/Joint
Muscular
Thinking/Cognition
Allergies

Describe your abilities/difficulties in the following area (include assistance required or equipment needed):

How is the issue for which you are seeking treatment affecting the following areas of your life?
No Effect Little Effect Some Effect Significant Effect Not Applicable
Friendships
Family
Job/School Performance
Financial Situation
Physical Health
Mood
Ability to Concentrate
Eating Habits
Sleeping Habits
Ability to Form Lasting Relationships
Ability to Control Anger

Authorization for Emergency Medical Treatment

Therapeutic Riding
Occupational Therapy/Hippotherapy

In the event of an emergency, contact:


In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize LifeStriders to:

1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.

Consent Plan

This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life saving'' by the physician. This provision will only be invoked if the person(s) above is unable to be reached.

Progress Reporting

At LifeStriders we strive to provide services that enhance the lives of individuals in a variety of ways. Please answer the following questions to help us design a program that fits the needs of our clients. Thank you.







  1. Other:






Participant’s Consent for Release of Information


  • Veronica Sosa
  • Chrystal Schipper
  • Amber Osterberger
  • LifeStriders Therapists
  • Intelirev

For the purpose of developing a therapeutic riding/equine activity program for the above named participant. The information to be released is marked below.









LifeStriders

Phone: 262.309.9297
Fax: 866.404.3105
counseling@lifestriders.org

Sll W29667 Summit Avenue (US HWY 18)
Waukesha, WI 53188

Participant's Application

Participant's Health History

Name Yes/No Comment

How is the issue for which you are seeking treatment affecting the following areas of your life?

Name Effect


Authorization for Emergency Medical Treatment

In the event of an emergency, contact:

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize LifeStriders to:

1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.

Consent Plan

This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life saving'' by the physician. This provision will only be invoked if the person(s) above is unable to be reached.

X
Signature Date

Progress Reporting

At LifeStriders we strive to provide services that enhance the lives of individuals in a variety of ways. Please answer the following questions to help us design a program that fits the needs of our clients. Thank you.






Consent for Release of Information

    • Veronica Sosa
    • Chrystal Schipper
    • Amber Osterberger
    • LifeStriders Therapists
    • Intelirev

Please send materials to:
LifeStriders Therapeudic Riding Center
S11 W29667 Summit Avenue (US HWY 18)
Waukesha, WI 53188

X
Client/Parent/Guardian Name Signature Date

PARTICIPATION WAIVER AND GUEST LIABILITY RELEASE AGREEMENT

As a participant/rider at LifeStriders Therapeutic Riding Center, I acknowledge the risks and potential risks of horseback-riding and equine relate activities. (Under the Wisconsin Equine Activity Civil Liability Act [WI Statute 895.481], each participant who engages in an equine activity expressly assumes the risks of engaging in and legal responsibility for injury, loss or damage to person or property resulting from the risk of equine activities) However, I feel that the possible benefits are greater than the risks 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 LifeStriders, Inc., its Board of Directors, Advisors, Board, Action Committee, Instructors, Therapists, Aids, Volunteers, and/or employees for any and all injuries sustained while participating in the LifeStriders Therapeutic Riding Program. All Volunteers and guests (guests = participants, siblings, parents, other relatives, friends) entering LifeStriders premises understand that they will be in contact with animals, and assume the risk of injury, and that it is possible that I or my guest(s) be bitten, scratched, and/or otherwise injured while on LifeStriders premises. I also understand that I or my guest(s) may be exposed to equine and/or other animal illness and disease and that it is also possible that I or my guest(s) could indirectly expose other animals to such illness and disease. My signature to this liability release attests to my, and my guest(s) intent to hold harmless and release from all liability against LifeStriders Inc., its Board of Directors, instructors, therapists, volunteers, and or employees for any and all injuries and or losses I or my guest(s) may sustain, while attending LifeStriders premises.

X
Participant's Name Signature Date

Photo Release

I



consent to and authorize the use and reproduction by LifeStriders 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 in benefit of tie program.

X
Signature Date

Safety Rules

LifeStriders strives to provide a safe riding experience for all of our participants and requires that all participants, families and volunteers abide by our safety regulations. Please review and sign our safety rules.

  • Please reserve parking in front of the building for Riders and Participants. Volunteer and Staff parking is available along the side and rear of the building.
  • To avoid traffic jams in the driveways please arrive earlier than your designated class time.
  • Parents/caregivers must keep siblings, friends and relatives of the rider in the Viewing Areas.
  • Please do not bring pets.
  • When a volunteer escorts a rider to the parents/caregiver, upon class completion, the parents/caregivers need to contain the rider to the Viewing Areas
  • Parents/caregivers will be solely responsible for their rider before and after arena/therapeutic riding time is completed
  • Parents/caregivers please walk to the gate to meet your rider after they have dismounted the horse. Once riders are done with arena/therapeutic riding time, parents/caregivers are asked to please help their rider with feeding treats to the horses.
  • Parents/caregivers need to remain on LifeStriders premises during therapeutic riding and/or Social skills group sessions.
  • For training and safety purposes, we ask that volunteers and participants NEVER HAND FEED THE HORSES.
  • Hitting or kicking of horses is NEVER allowed, and will result in dismissal from the program.
  • NO guns, knives, weapons or violence of any kind are allowed on LifeStriders premises. This is a zero tolerance rule. Violators will be asked to leave and not allowed to return.
  • Please do not climb or lean on any fences, gates or doors.
  • No one is to enter the Barn Manager’s apartment or other buildings on the property, other than the barn.
  • In order to ensure the safest riding conditions, we ask that children and visitors refrain from screaming, running, or ball playing on the premises.
  • Only the rider and staff/volunteers are allowed in the teaching arena, unless parent or health care professional presence is requested by instructor.
  • Please keep the guidance given to riders in alignment with the therapeutic riding instructor’s directions.
  • Attire

  • A helmet must be worn at all times during the lesson hour.
  • Riders MUST wear long pants to ride, jeans are preferred.
  • All Riders must wear shoes. No one will be allowed to ride or be around the horses if they are bare foot or in sandals. We prefer the shoes have a ¼” heel rather than tennis-type shoes. Volunteers must wear sturdy non-opened toed shoes. We do not recommend steel-toed shoes.
  • Volunteers- Please refrain from wearing clothes that is too tight or revealing- No tank tops, bra tops etc.

I have read and understand LifeStriders Safety Policy

X
Participant's Name Signature Date

DISMISSAL OF VOLUNTEERS AND GUESTS FROM CENTER ACTIVITIES

LifeStriders relies greatly on volunteers as important members of the team who provide services to and assist our clients. We also recognize the extreme importance of the safety and well-being of our clients, volunteers, staff, guests and animals. All Volunteers and guests (guests = participants, siblings, parents, other relatives, friends) are expected to follow LifeStriders rules and policies and may not engage in disruptive, unsafe or inappropriate behavior. In the event a volunteer or guest does not comply, the following actions may be taken:

  • Level 1 : Verbal Warning

    Breaking of LifeStriders rules and /or policies and procedures may be followed by a verbal warning from LifeStriders Staff to be documented in the incident report book.

  • Level 2 : Written Warning

    Breaking of LifeStriders rules and/or policies and procedures for a second time will be followed by a Personnel/Staff meeting for discussion regarding the infraction. The purpose of the meeting is to determine the exact reason the infraction occurred for second time and discuss with the volunteer/guest how to avoid the circumstance ever occurring again. This meeting will be documented and placed in the incident report book.

  • Level 3 : Dismissal from Organization

    Immediate dismissal from the property and organization will occur for:

    1. Endangering the safety of others
    2. Inappropriate use of the facilities, mailing lists or monies
    3. Disruptive or abusive behavior to the animals or individuals at LifeStriders
    4. Repeated disregard of the organizations rules, policies and procedures
    5. Possession of a weapon, illegal drugs or a paraphernalia
    6. Being under the influence of alcohol or drugs

I have read and understand the policies and program rules by which LifeStriders operates. By signing below, I indicate my willingness to abide by these rules and policies. I further understand that failure to comply with these policies and rules will result in discharge from the program.

X
Participant's Name Signature Date

LifeStriders Make-up and Payment Policy

LifeStriders offers but does not guarantee, one make-up ride per session for any missed classes based on availability. LifeStriders will offer Two (2) opportunities for make-up dates, if those dates are not used the make-up credit will expire. Make-up credits will expire at the end of each session. LifeStriders accepts, check, money order or Major Credit Cards as form of payment.
PAYMENT POLICY: LifeStriders is a non-profit organization that is committed to offering accessible therapeutic services to our community. We raise funds to offset the cost for parents or participants paying out of pocket and who are not receiving any form of assistance through county agencies, grants, funds etc. One of the ways we are able to keep our prices significantly below going rates is by minimizing accounting costs. LifeStriders charges $30.00/per therapeutic hour if paid in advance or $65.00/per therapeutic hour (45-50 minutes) if paid one (1) week past the session start date, if the participant receives any source of outside funding, or if the participant chooses to stop after starting the session. We ask that the entire session be paid in advance to reserve a spot. ** Billing County Agencies- If you or your child or foster child has a case with Milwaukee County and billing has been paid through them in the past, we will continue to bill them unless you tell us otherwise. Parents/foster parents/guardians must email us of any changes in billing agencies, case managers or responsible parties in advance. If payment is not received, the parents/foster parents/guardians are responsible for any outstanding fees.
** BILLING INSURANCE for OCCUPATIONAL THERAPY - LifeStriders will bill patient’s insurance agency at the rate of $400.00 per therapeutic hour (45-50 minutes). Deductible, co-pay’s and co-insurance payments are the responsibility of the named insured card holder/parent/guardian. If billing has been paid through Insurance in the past, LifeStriders will continue to bill insurance unless told otherwise. Participant/Parent/Guardian will email/contact LifeStriders of any changes in insurance plans, or responsible parties in advance. If payment is not received for any dates of service, participant/parent/guardian understands that they assume responsibility for any outstanding fees at the out of pocket rate of $100.00 per therapeutic hour.
SUMMER OCCUPATIONAL THERAPY PROGRAM requires a deposit of $500 to reserve a spot for the nine (9) week program. If participant chooses to vacate their reserved time slot after June 1, 2016, the $500.00 deposit will be retained by LifeStriders to pay for the time slot reserved. If patients insurance does not cover services, patient/parent/guardian will be responsible to pay the out of pocket rate of $100.00 per therapeutic hour. The $500.00 deposit will be applied to patient’s bill.
CANCELLATION POLICY FOR OCCUPATIONAL THERAPY SERVICES Twenty-four (24) hour advance notice is required for cancellation of appointments, I am aware that I will be charged according to the scheduled fee of $65 if the cancellation is made with less than a twenty-four (24) hour notice

I have read and understand the make-up and payment policies by which LifeStriders operates. By signing below, I indicate my willingness to abide by these rules and policies.

X
Participant's Name Signature Date