Welcome to Lil’ Folk Farm’s Therapeutic Riding Program Lil’ Folk Farm provides horseback riding lessons and other related equine assistant activities to individuals with disabilities. The mission of our program is to encourage self-growth through physical, social, educational, and behavioral benefits through equine-related interaction. Our Therapeutic Riding Program follows PATH International (Professional Association of Therapeutic Horsemanship International) guidelines. Enclosed you will find information about our program and forms for enrollment. The responsible persons must complete ALL forms and ALL forms must be returned to begin enrollment. Equine assisted activities are formed around each person’s abilities. In order for each rider to benefit the most in their lessons, every effort is made to match the rider's abilities with the proper horse and volunteers. Forms can be mailed in prior to your intake evaluation with one of our PATH Certified Instructors or handed in at the beginning of the evaluation.
Rider Enrollment Packet ENROLLMENT & ATTENDANCE: Please fill out and sign the enclosed forms completely and return them to Lil’ Folk Farm. A lesson time will be scheduled as soon as all forms are completed and an appropriate time slot is available. Lessons are half hour privates and a parent, guardian or caregiver are required to remain on premises during the lesson. CANCELLATION/MAKE UP POLICY: Please notify us if you will not be coming to your regularly scheduled lesson. If you give us at least 24 hours advanced notice, we may be able to reschedule your lesson for a different day/time. However, rescheduled lessons are not guaranteed and no refunds are given for lessons missed. PROGRAM FEE POLICY: Lessons are $65 for half hour private. students arrive 15 mins. prior to lesson time to prepare to mount. To make payment easy, we hold credit cards on file and bill out at the beginning of the month for the month. CALENDAR OF RIDING: Lil’ Folk Farm holds classes on a daily basis (Monday – Saturday). We do close for all major holidays and take a Spring Break(week around july 4th, Winter Break(week around christmas) and Summer Break (week prior to labor day). Please pay attention to email announcements for program information and upcoming closed dates. Also, during times of stormy weather or extreme heat, classes may be cancelled at the discretion of the staff and for your safety. In these cases you will be notified through email or a call from your instructor APPAREL: ASTM approved Riding helmets are provided at the facility or you may provide your own. Riders should dress appropriately for the current weather conditions. Please wear long pants and boots or sneakers (no sandals) for horseback riding. Boots can be Riding Paddock boots , Hiking Boots or work boots but please no Winter snow boots- for safety. PARKING: We have spots right in front of the indoor arena for handicapped parking. If you have visitors come to watch you ride, please have them park in our main parking lot to leave the Handicapped spots for those that need them. CONTACT INFO: You will be provided your instructor’s Individual contact information. We send out program info through email and the farm address, phone and email is below: Lil’ Folk Farm Therapeutic Riding David and Nancy Dubin 1070 Washington St. Holliston, Mass. 01746 www.lilfolkfarm.com
[email protected](508)429-1700
RIDER/PARENT INFORMATION SHEET Student’s Name________________________________________ Date of Birth ___________Gender _________________________ Current Diagnosis_______________________________________ Current Treatment/Services________________________________ ___________________________________________________ Primary Caregiver__________________ Relationship___________ Address____________________City & zip___________________ Phone____________________ E-mail___________________ Mother’s Name______________Cell Number_______________ Occupation________________ Work Number______________ Father’s Name_________________Cell Number ____________ Occupation____________________ Work Number___________ Please let us know if you can help the program in any of the following ways:
Leader (horse experience desirable)
Side walker
Other ways I can help: _____________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ Lil’ Folk Farm Therapeutic Riding David and Nancy Dubin 1070 Washington St. Holliston, Mass. 01746
[email protected] (508)429-1700
Questionnaire & Health History Has the student had previous experience with therapeutic riding? YES NO If yes, please explain... ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Goals: What are you hoping to accomplish by participating ? ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Comments: please give any info that you feel will be helpful in lesson planning ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Please answer the following to help us best prepare for your arrival and evaluation
Does the student... YES walk independently? Have poor balance sitting/standing balance? Have speech?language difficulties Have problems with fine motor skills? Have problems with gross motor skills? Have allergies or breathing problems? Have a history with seizures? Have a emotional/behavioral problems? Have heart /circulation problems? Have short term/long term memory loss? Have a fear of heights? Have a fear of horses?
NO
COMMENT
PHYSICIAN’S REFERRAL FORM To be signed and dated by current Doctor
Patient’s Name:___________________________________________________ Patient’s date of birth:_______________ Height:______Weight:_______
Medical History Diagnosis:__________________________Date of onset:__________________ Primary Disability: _________________________________________________ Other Concerns:____________________________________________________ Hospitalizations:____________________________________________________ Shunts/Assistive Devices: ___________________________________________ Seizures/Allergies: _________________________________________________ Present Medications:_________________________________________________ __________________________________________________________________
Physical Evaluation Skin/Circulation______________________Neuro/Sensation ______________ Heart/Lungs_______________________ Balance/Coordination_______________ Bowel_____________________________ Bladder ___________________________ Vision___________________________ Hearing___________________________ Speech______________________________Spasticity/Rigidity _________________ Other________________________________________________________________ Precautions/Contraindications to Therapeutic Horseback Riding:_________________ ____________________________________________________________________
In my opinion, this patient is able to receive therapeutic horseback riding instruction under appropriate supervision at Lil’ Folk Farm _______________________ ____________________ Physician’s Signature
Date
Physician’s Name_____________________________
Phone _____________________
Office Address _____________________________________ City & Zip _____________________________________ _____________________________________ Parent/Guardian Signature
__________________________ Date
THERAPIST REFERRAL FORM If student is currently seeing a physical, occupational or speech therapist, please have them fill out this form and/or attach a recent evaluation.
Name of Student________________________
Birthdate_______
Diagnosis:__________________________________________ Current Therapy: _____________________________________ Evaluations Used:_____________________________________ SHORT TERM GOALS:__________________________________ __________________________________________________ LONG TERM GOALS:___________________________________ ___________________________________________________ OBJECTIVES:_________________________________________ AREAS OF WEAKNESS:_________________________________ __________________________________________________ AREAS OF STRENGTH: ___________________________________________________ ___________________________________________________ PRECAUTIONS: _______________________________________ CUES: ______________________________________________ OTHER:_____________________________________________ ______________________ Therapist Signature
__________________ Date
_______________________ Parent Signature Date
___________________ Date
Lil’ Folk Farm Therapeutic Riding David and Nancy Dubin 1070 Washington St. Holliston, Mass. 01746 www.lilfolkfarm.com
[email protected](508)429-1700
RELEASE OF LIABILITY AGREEMENT PLEASE READ CAREFULLY AND DO NOT SIGN UNLESS YOU FULLY UNDERSTAND.
STUDENTS NAME_______________________________DATE OF BIRTH______________________ ADDRESS ____________________________________________________________________________ IF UNDER AGE 18: PARENT GUARDIAN________________________________________________ ADDRESS________________________________________EMAIL_________________________ TEL#: HOME(
)____________________WORK(
)______________CELL(
)____________
I ACKNOWLEDGE THAT I HAVE BEEN FULLY INFORMED OF AND UNDERSTAND THE INHERENT AND ACTUAL RISKS OF INJURY INVOLVED IN HORSEBACK RIDING GENERALLY AND IN LEARNING TO RIDE/HANDLE HORSES/PONIES IN PARTICULAR. IN TAKING LESSONS/CLASSES AT LIL’ FOLK FARM LLC, I ASSUME ANY SUCH RISK OF INJURY AND FURTHER, I VOLUNTARILY RELEASE LIL’ FOLK FARM LLC, IT’S OWNERS,INSTRUCTORS/TEACHERS, AND AGENTS FROM ANY RESPONSIBILITY ON ACCOUNT OF ANY INJURY I OR MY CHILD/CHILDREN OR WARD MAY SUSTAIN WHILE RECEIVING INSTRUCTION,PARTICIPATING IN HORSE SHOWS,TRAIL RIDES,PONY RIDES,VOLUNTEERING OR WHILE RIDING IN CONNECTION THERE WITH, AND I AGREE TO INDEMNIFY AND HOLD HARMLESS LIL’ FOLK FARM LLC, IT’S OWNER’S,INSTRUCTORS/TEACHERS AND AGENTS ON ACCOUNT OF ANY SUCH CLAIM. FURTHERMORE, I AGREE TO INDEMNIFY AND HOLD HARMLESS THE OWNER(S) OF ANY HORSE I OR MY CHILD OR WARD RIDE/HANDLE AT LIL’ FOLK FARM LLC, ON ACCOUNT OF ANY SUCH CLAIM.
WARNING UNDER MASSACHUSETTS LAW, AN EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO, OR DEATH OF, A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES, PURSUANT TO CHAPTER 128,SECTION 2D OF THE GENERAL LAWS. STUDENT SIGNATURE_____________________________ DATE_____________(if 18 or older) PARENT OR GUARDIAN SIGNATURE_____________________________DATE___________ SECOND PARENT OR GUARDIAN SIGNATURE_______________________DATE_____________ WHERE APPLICABLE, PLEASE HAVE BOTH PARENTS/GUARDIANS SIGN MEDICAL AUTHORIZATION
IN THE EVENT THAT THE ABOVE-NAMED STUDENT REQUIRES EMERGENCY MEDICAL TREATMENT ON ACCOUNT OF ANY ACCIDENT OR INJURY WHICH MAY OCCUR WITH ANY ACTIVITIES AT LIL’ FOLK FARM LLC THE EMERGENCY MEDICAL PERSONAL CONTACTED BY LIL’ FOLK FARM LLC ARE HERBY GIVEN FULL AUTHORITY TO PROVIDE ALL SUCH NECESSARY EMERGENCY MEDICAL TREATMENT FOR THE ABOVE NAMED STUDENT INCLUDING PERMISSION FOR THE ADMINISTRATION OF ANESTHESIA.
STUDENT_______________________________________DATE________________________ PARENT/GUARDIAN_____________________________DATE________________________ IN CASE OF EMERGENCY, PLEASE CONTACT NAME______________________HOME# ____________________CELL#________________________ NAME______________________HOME#___________________CELL #_________________________
AUTHORIZATION FOR MEDICAL TREATMENT Name of Rider_______________________________________ Name of Parent ______________________________________ Rider’s Date of Birth ___________________________________ Current Diagnosis _____________________________________ Current Medications___________________________________ Allergies to Food/ Medications ___________________________ Date of Last Tetanus Shot________________________________ Any special Instructions___________________________________________ ___________________________________________________ In the event that emergency medical treatment is required due to an illness or injury during a therapeutic riding session, I authorize Lil’ Folk Farm to: 1. Call emergency medical help and consent to any necessary treatment that may include transportation, x-ray examination, surgery, medication, or hospitalization. 2. Release student records upon request of authorized emergency medical personnel if needed. It is understood that every effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. ______________________ Consent Signature
___________________ Date
__________________________________________________ Print Name and Relationship Telephone numbers where parents can be reached: Mother____________________
Father___________________
Lil’ Folk Farm Therapeutic Riding David and Nancy Dubin 1070 Washington St. Holliston, Mass. 01746 www.lilfolkfarm.com
[email protected](508)429-1700
PHOTO RELEASE FORM The undersigned hereby grants Lil’ Folk Farm Therapeutic Program permission to take or have taken still or moving photographs of my self/ daughter/ son________________________ . The undersigned also authorizes Lil’ Folk Farm to use such photographs in its advertising, news media, brochures, pamphlets, and instructional material. Date __________________________________ Signed_________________________________
RESEARCH DATA RELEASE FORM The undersigned hereby grants permission to use all test results and scores obtained from evaluations, both formal and informal of____________ while said person is in attendance at Lil’ Folk Farm Therapeutic Program. Aforesaid material will be used for the purpose of research and conducted by Lil Folk Farm and Lil’ Folk Farm staff or consultants. No use of this data will be included in published material. _______________ Date Signed ______________________________________________________
SIGNED
Lil’ Folk Farm Therapeutic Riding David and Nancy Dubin 1070 Washington St. Holliston, Mass. 01746 www.lilfolkfarm.com
[email protected](508)429-1700
RIDERS WITH DOWN SYNDROME Lil’ Folk Farm, a member of PATH (Professional Association of Therapeutic Horsemanship), supports the position taken by PATH regarding the necessity for X-rays of all Down Syndrome riders. It is recommended that all Down Syndrome riders have X-rays to determine if Atlantoaxial Instability is present. AI, simply explained, is an instability or dislocation of the joints between the first and second cervical vertebrae that could result in serious injury or paralysis. Please ensure your child’s safety by having an X-ray taken and read by a qualified physician. By signing below you agree that you have read and understand this precaution. Name of Rider___________________________________ Parent/Guardian ________________________________ Date of Exam _______________________________ Results of Exam _____________________________________
______________________ Parent/Guardian Signature ____________________ Date Lil’ Folk Farm Therapeutic Riding David and Nancy Dubin 1070 Washington St. Holliston, Mass. 01746 www.lilfolkfarm.com
[email protected](508)429-1700
