Rider Registration
Participant must first be pre-approved for a spot in the program prior to completing and submitting a rider registration form. No client can participate in a class without a current Rider Registration signed by the client or legal guardian.
Back
Next
Date
-
Month
-
Day
Year
Is the participant attending through an Indigenous run school program?
Yes
No
Which program are you participating in?
Atakokan Program
KFN Program
Back
Next
Participant Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Back
Next
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Client Email
*
example@example.com
Client Preferred Phone No#
*
Back
Next
Is the participant 18 years old or older?
*
Yes
No
Does the participant attend SD71?
Yes
No
Does the participant have Indigenous Ancestry?
Yes
No
Back
Next
Does the participant have a legal guardian?
Yes
No
Parent or Legal Guardian
*
First Name
Last Name
2nd Parent or Legal Guardian
First Name
Last Name
Emergency Contact
*
First Name
Last Name
Contact Phone No#
*
Please enter a valid phone number.
Back
Next
Participant Age
Weight
*
(maximum 150 lbs)
Height
*
(maximum 5'10")
Has the participant ever had a seizure?
*
Please Select
No
Yes, within the last 6 months
Yes, within the last 12 months
Yes, over a year ago
Has the participant ever had a concussion?
*
Please Select
No
Yes, within the last 6 months
Yes, within the last 12 months
Yes, over a year ago
Back
Next
Will you be using Funding from any of the following Funding Organizations?
*
Autism Funding
At Home Funding
Heritage Christian Online School
Partners in Education (PIE)
Self Design
Jordan's Principle
No, I do not have funding
Back
Next
Fee for Funded Riders
Fee Rate for Funded Riders except 'At Home Funding'(this list is information only - no entry required):
Fee Rate for 'At Home Funding' Funded Riders (this list is information only - no entry required):
Up-to-date Confirmation of Funding is required two weeks prior to the first day of your session. Please indicate what documentation you will be providing.
Up-to-date Confirmation of Funding is required two weeks prior to the first day of your session. Please indicate what documentation you will be providing.
Back
Next
A $200.00 Deposit is Required for Riders using Autism Funding before the beginning of each term.
Autism Funding does not re-imburse service providers for any classes the rider does not attend. As the entire term is allotted to a specific rider, CVTRS must recover the fee for every class. This deposit will be applied to missed classes. Before each riding term the deposit must be topped up again to $200. Any unused deposit will be re-imbursed at the end of the program year in June or when the participate leaves the program.
The deposit will become non-refundable when (this list is information only - no entry required):
I have read and agree to CVTRS's Deposit Policy for funded riders
Yes
Back
Next
Fee and Deposit Policy
For Riders that are self-funded. This includes riders who will be applying for Jumpstart and Kidsport grants.
Fee Rate (this list is information only - no entry required):
You will be e-mailed an invoice for the first term upon registration, and then for each subsequent term a couple of weeks before they begin.
A minimum deposit of 50% of the first riding term is required upon registration. Subsequent riding terms must be paid in full 2 weeks prior to the start date of each term.
I have read and agree to CVTRS's Fee and Deposit Policy
*
Yes
Back
Next
Jumpstart and Kidsport Grants
You may be eligible to apply for a grant from Jumpstart or Kidsport toward rider fees. If a Jumpstart or Kidsport grant is subsequently received by CVTRS, then the rider fee will be re-imbursed equal to the amount of the grant received.
Yes, I will be applying for the following grants:
Jumpstart
Kidsport
Other
Back
Next
Attendance Policy
Riders should arrive 10-15 minutes before class start time.
This allows time for the riders to settle in, use the washroom if needed, and get their safety equipment on.
Notice is Required if the Participant will miss a class
If you are unable to attend a class, it is important that you call us at least 2 hours before your scheduled class time so that we can cancel our dedicated volunteers. Many of our volunteers live a considerable distance from the barn and travel at their own expense to attend your class. Our volunteers give us their valuable time. There would not be a therapeutic riding program without our volunteers. Please show them your respect and appreciation by notifying us as early as possible if you are unable to attend a class.
Back
Next
Late Arrivals
If you arrive late for class, you may be unable to ride that day. It is unfair to your riding partners to have to wait for your arrival. Furthermore, your volunteers will have been sent home, and your horse untacked and put out to pasture.*If you know that you are going to be late call us to avoid missing your class if possible. No refunds will be given for late or missed classes.
Class Cancellations
If classes are cancelled by CVTRS due to scheduling issues or poor weather conditions, the fee for that day will be credited to your account or refunded to you.
I have read, understood and agree to the Attendance Policy
*
Yes
Back
Next
CVTRS Discharge Policy
Riders may be asked to leave the program for a number of reasons, including but not limited to (this list is information only - no entry required):
I have read, understood and agree to the Discharge Policy
*
Yes
Back
Next
CVTRS's Standards / Policy
The goal of this policy is to ensure a safe riding environment for therapeutic riding clients, volunteers and staff. This policy refers to all types of clients including, but not limited to, riders, drivers, grooming participants, campers, day program participants.
No client can be accepted until this form has been completed by the client or parent and/or guardian.
CVTRS clients are under strict supervision and although every effort will be made to avoid an accident, NO LIABILITY can be accepted by any of the organizations concerned including the BOARD OF DIRECTORS, STAFF, VOLUNTEERS, REPRESENTATIVES, SUCCESSORS, AGENTS, OR ASSIGNS and anyone associated with the COMOX VALLEY THERAPEUTIC RIDING SOCIETY, and THE COMOX VALLEY REGIONAL DISTRICT in the event of any accident occurring. There are inherit dangers, hazards and risks (collectively “risks”) associated with equine activities and injuries resulting from the “risks” are a common occurrence. The “risks” of “equine activities” mean those dangerous conditions which are an integral part of equine activities, including but not limited to:
Back
Next
1. The propensity of any equine to behave in ways that may result in injury, harm or death to persons on or around them and to potentially collide with, bite or kick other animals, people or objects.
2. The unpredictability of an equine’s reaction to such things as sounds, sudden movements, tremors, vibrations, unfamiliar objects, persons or other animals and hazards such as subsurface objects.
3. The potential of participants behaving in a negligent manner that may contribute to injury to themselves or others, including failing to act within their abilities to maintain control over an equine.
I have read and understood and agree to CVTRS's Standards Policy
*
Yes
Back
Next
Seizure Policy
Incoming Applicants:
SEIZURES New clients with a prior history of seizures who are applying for admission to CanTRA accredited center’s must, at the time of application, have been seizure-free for 6 months on medication OR for one year without medication
Exception: Clients that experience ‘absence’ seizures (seizures that do not affect balance, posture or tone) would be permitted to ride if they always have a leader to control the horse and a sidewalker to ensure safety in the case of an absence seizure while riding. Riders with absence seizures may not ride independently. The above criteria also applies to all riders with a history of seizures, participating in a therapeutic riding program .
Back
Next
One-time seizures:
In the case where a rider with no history of seizures experiences a one-time seizure or seizure-like event, the rider will be required to discontinue riding until they have been approved by the centre’s medical committee to re-enter the program. If the centre does not have a medical committee, then the decision for a rider to return will be made by the Executive Director/ Managing Director (and/or the Head Instructor). This decision can only be made once the appropriate investigation and paperwork have been completed:
1. Documentation from the doctor must be provided to the centre, stating an opinion as to whether the episode was or was not a seizure.
2. If the doctor deems it a seizure, the same waiting period would apply as for a rider new to the program (see above).
3. If the doctor feels it was not a seizure, the rider may return to lessons as usual.
I have read, understood and agree to the Seizure Policy
*
Yes
Back
Next
Client Consent and Release Form Policy
A. AGREEMENT SCOPE AND TERRITORY AND DEFINITIONS – This agreement shall be legally binding upon me the registered RIDER, and the parents or legal guardians thereof if a minor, my heirs, estate, assigns, including all minor children, and personal representatives. The term “HORSE” herein shall refer to all equine species. The term “HORSEBACK RIDING” or “RIDING” herein shall refer to riding or otherwise handling of horses, ponies, mules, or donkeys, whether from the ground or mounted. The term “RIDER” shall herein refer to a person who rides a horse mounted or otherwise handles or comes near a horse from the ground. The terms “I”, “me”, “my” shall herein refer to the above registered rider and the parents or legal guardians thereof if a minor.
Back
Next
B. ACTIVITY RISK CLASSIFICATION – Horseback riding is classified as RUGGED ADVENTURE RECREATIONAL SPORT ACTIVITY , in that there are numerous obvious and nonobvious inherent risks always present in such activity despite all safety precautions. Related injuries can be severe, requiring more hospital days and resulting in more lasting residual effects than injuries in other activities.
C. NATURE OF RIDING HORSES – No horse is a completely safe horse. Horses are 5 to 15 times larger, 20 to 40 times more powerful, and 3 to 4 times faster than a human. If a rider falls from a horse to ground it will generally be at a distance of from 31/2 to 51/2 feet, and the impact may result in injury to the rider. Horseback riding is the only sport where on much smaller, weaker predator animal (human) tries to impose its will on, and become on unit of movement with, another much larger, stronger prey animal with a mind of its own (horse) and each has a limited understanding of the other. If a horse is frightened or provoked it may divert from its training and act according to its natural survival instincts which may include, but are not limited to: stopping short, changing directions or speed at will; shifting its weight; bucking; rearing; kicking; biting; or running from danger.
Back
Next
D.CONDITIONS OF NATURE - CVTRS is NOT responsible for total or partial acts, occurrences, or elements of nature that can scare a horse, cause it to fall, or react in some other unsafe way. SOME EXAMPLES ARE: thunder, lightning, rain, wind, wild and domestic animals, insects, reptiles, which may walk, run, fly near, bite and/or sting a horse or person; and irregular footing on out-of-door groomed or wild land which is subject to constant change in condition according to weather, temperature, and natural and man-made changes in landscape.
E. INPSECTION OF PREMISES – RIDER and/or LEGAL GUARDIAN has inspected CVTRS’s facilities and trails and is satisfied that all premises conditions are reasonably safe for RIDER’S intended purpose, usage and presence upon the CVTRS premises.
F. ACCIDENT/MEDICAL AND PERSONAL LIABILITY – Should medical treatment be required, I and/or my own accident/medical insurance company shall pay for all such incurred expenses.
Back
Next
G. PROTECTIVE HEADGEAR WARNING – I have been fully warned and advised by CVTRS that the RIDER must wear protective headgear (riding helmet), and that the wearing of such headgear while mounting, riding, dismounting, and otherwise being around horses, may prevent or reduce severity of some head injuries and even prevent death from happening as the result of a fall or other occurrence.
H. LIABILITY RELEASE – In consideration of CVTRS allowing my participation in this activity, under the terms set forth herein, I, the RIDER, and the parent or guardian thereof if a minor, do agree to hold harmless and release CVTRS, its owners, agents, employees, officers, members, premises owners, insurers, and affiliated organizations from legal liability due to CVTRS ordinary negligence; and I do further agree that except in the event of CVTRS’s gross negligence and willful and wanton misconduct, I shall not bring any claims, demand, legal actions and causes of action, against CVTRS and/or its associates, for any economic and non-economic losses due to bodily injury, death, property damage, sustained by me and/or my minor child or legal ward in relation to the premises and operations of CVTRS, to include while riding, handling, or otherwise being near horses owned by or in the care, custody and control of CVTRS.
I have read, understood and agree to the Client Consent and Release Form Policy
*
Yes
Back
Next
Release of Information Consent
I hereby authorize the Comox Valley Therapeutic Riding Society to release to its instructors and/or facilitators such information as may be necessary to conduct a beneficial and safe riding program for the client. The information to be released is marked below.
Medical history
Physiotherapy/occupational therapy evaluation, assessment and program plan
Speech therapy evaluation, assessment and program planType option 3
School counselor and/or other School District support staff
Name and number of others that may be contacted to obtain or share information with
Other
Release of Information consent
*
Yes
Back
Next
Client Photo Release
For valuable consideration given and which is hereby acknowledged, the undersigned hereby grant to the Comox Valley Therapeutic Riding Society permission to take or have taken, still and moving photographs and films including television pictures of our son/daughter/ward and consents and authorizes the Comox Valley Therapeutic Riding Society its advertising agencies, news media and any other persons interested in the Comox Valley Therapeutic Riding Society and it’s work, to the use and reproduce the photographs, films and pictures to circulate and publicize the same by all means including without limited the generality of the foregoing, newspapers, television media, papers, presentations and clinical material. With regard to the foregoing material, no inducements or promises have been made to us/me to secure our/my signature(s) to this release other than the intention of the Comox Valley Riding Therapeutic Riding Society to use or be used such photographs, films and pictures for the primary purpose of promoting and aiding the Comox Valley Therapeutic Riding Society and it works.
Photo Release consent
*
Yes
No
Back
Next
Degree of Bodily Contact Policy
Due to the nature of the work at the Comox Valley Therapeutic Riding Society it is understood that instructors and trained volunteers will need to physically assist the majority of riders in one or more of the following areas and it is understood that this is part of the therapy/recreation sessions to which parents and riders have consented. A. When mounting, dismounting or riding a horse, B. It may be necessary to lift a rider onto the horse, to correct posture by placing hands at the front or back of the trunk, or to correct leg and hand positions, C. During riding sessions it may be necessary to quickly physically remove a rider from the group, due to behavioral or other concerns, and that this is done for the well-being of all concerned. This may involve two staff members lifting a rider. D. Any bodily contact provided by the trained staff or personal care workers is in the interest of providing a safe and fun environment for the rider, and will be undertaken with the utmost discretion.
I have read, understood and agree to the Degree of Bodily Contact Policy:
*
Yes
Back
Next
PLEASE INDICATE IF YOU HAVE ANY OF THESE CONTRAINDICATIONS, OR ANY OTHER MEDICAL CONDITIONS PROCLIVATIVE TO EQUINE ACTIVITES
ORTHOPEDIC
Acute herniated disk
Altanto-axial instability
Coxa arthrosis (degeneration of the hip joint)
Osteoporosis (severe)
Pathological fractures (e.g. osteogenesis imperfecta)
Spinal fusion, organic or operative (e.g. Harrington rods)
Spondylolisthesis
Structural scoliosis greater than 25-30 degrees or excessive kyphosis or lordosis; hemi vertebrae
Unstable spine including subluxation of the cervical spine
Other
Back
Next
MEDICAL
Acute stage of arthritis
Anti-coagulant medication
Concussion
CVA - secondary to unclipped aneurysm, or presence of other aneurysms - secondary to angioma that was not totally resected
Drug dosages causing physical states inappropriate to riding environment
Exacerbation of multiple sclerosis
Hemophilia
Open pressure sores and/or wounds on contact surfaces
Uncontrolled Seizures
Other
Back
Next
OTHER
Complete quadriplegia secondary to spinal cord injury
Moderate agitation with severe confusion/gross disruptive behaviour
Weight Limit 150 LBS and height limit 5'10" * Each rider is individual, riding will be based on safety and availability of horses*
Other
Back
Next
Additional Information
Participant Name
First Name
Last Name
Does the Participant have any allergies?
*
Yes
No
Allergy Information:
Medications:
Visual Defects:
Auditory Defects:
Back
Next
Speech Defects:
Neuro Sensation:
Balance:
Co-ordination:
Spasticity and/or Rigidity:
Back
Next
Reason for Referral:
Expectations from this referral:
Precautions & Comments:
Back
Next
Mobility Status:
Does the participant use a wheelchair?
Yes
No
Can the participant propel the wheelchair?
Yes
No
Can the participant ambulate?
Yes
No
Back
Next
Assistance:
Independent
Minimal
Moderate
Maximal
Physical Aids:
Canes
Crutches
Walker
Braces
Other, please describe
Details of other physical aids and/or type of braces
Back
Next
SIGNER STATEMENT OF AWARENESS
I/WE, THE UNDERSIGNED, HAVE READ AND DO UNDERSTAND THE FOREGOING AGREEMENT, WARNINGS, RELEASE AND ASSUMPTION OF RISK. I/WE FURTHER ATTEST THAT ALL FACTS RELATING TO THE APPLICANT ARE TRUE AND ACCURATE.
Participant Name
First Name
Last Name
Parent or Legal Guardian
First Name
Last Name
Signature
*
Back
Next
Emergency Information to Give to Ambulance Attendant
Please fill in the document below. In the event of an emergency, we will send this document along with the participant to the hospital.
Date:
-
Month
-
Day
Year
Date
Participant Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Health Care Card #:
Parent or Legal Guardian
First Parent / Guardian
Last Name
2nd Parent or Legal Guardian
Second Parent / Guardian
Last Name
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
Province
Postal
Family Doctor
Family Doctor Phone no#
Please enter a valid phone number.
Does the Participant have any allergies?
Yes
No
Allergy Information:
Does the Participant have a medical diagnosis?
Yes
No
Medical Diagnosis:
Is the participant on any medications?
Yes
No
Medications:
Seizure History:
Please Select
No
Yes, within the last 6 months
Yes, within the last 12 months
Yes, over a year ago
Concussion History
Please Select
No
Yes, within the last 6 months
Yes, within the last 12 months
Yes, over a year ago
Other Pertinent Information:
seizure history, concussion history, etc.
Submit
Submit
Should be Empty: