R.O.C.K., Ride On Center for Kids
PO Box 2422 Georgetown, TX 78627
2050 Rockride Lane, Georgetown, TX 78626
(512) 930-7625 office
(512) 863-9231 fax
www.rockride.org
Dear Prospective R.O.C.K. Client:
We welcome your interest in the R.O.C.K. Equine Assisted Activities and therapies. We look forward to working with
you to accomplish your goals and to enjoy the experience of horsemanship and therapy in a fun and successful
environment.
In order to provide the best benefit and the safest environment to our clients, R.O.C.K. has established some guidelines
for acceptance into the program:
 It is recommended that clients be at least 2 years of age for Equine Assisited Therapies (i.e. PT, Speech, or
HPOT).
 It is recommended that clients be at least 4 years of age and have emerging head and neck control for
Therapeutic Horsemanship.
 To protect our clients, volunteers and horses, weight guidelines have been established. Please refer to the
Client Guidelines page in this packet.
 Please review the attached list of precautions and contraindications (found on the cover letter to your health
care provider). If the individual has one or more of these conditions, therapeutic horsemanship and/ or equine
assisted therapies may not be recommended. Please contact our office (512)930-7625 if you have any questions
or need additional information.
Please note that the “Client Medical History and Physician’s Statement” form must be completed and signed by your
physician. All forms must be completed and returned before the client can be considered for the program. If you are a
new client, once all completed forms are returned, we will contact you to schedule a new client screening.
In this packet, you will find other useful information about our program, goals, and fees. If you have email access, please
note it on the registration form. A great deal of information is disseminated to our students and volunteers
electronically. Please contact Kristin Witcher, Services Director, if you have any questions concerning the process. We
look forward to working with you.
Please mail forms to:
R.O.C.K.
PO Box 2422
Georgetown, Texas 78627
R.O.C.K. Mission: Improving independence and life skills, in partnership with the horse.
R.O.C.K. Vision: To be the trusted leader in equine-assisted actives through service, research, and higher learning.
Page 1 of 12
R.O.C.K., Ride On Center for Kids
PO Box 2422 Georgetown, TX 78627
2050 Rockride Lane, Georgetown, TX 78626
(512) 930-7625 office
(512) 863-9231 fax
www.rockride.org
Program Overview
We provide many programs. Please check the ones that you are interested in.
Equine Assisted Activities and Therapies/Therapeutic Horsemanship- These sessions are 45 minutes and
include mounted and un-mounted activities. They may include riding skills, fitness exercises, horse care, arena
preparation and team building. Each session includes individualized goals. Horses are an essential part of the
team- they facilitate learning, motivation and group skill building.
Types of Equine Assisted Activities or Therapies:
 Private session- This is one instructor and one client. This is the only option for the clients paid by a service
provider (DSSW, Scoggins, DARS…).
 Semi-Private session- This is one instructor and two clients. This option is not available for clients paid by a
service provider (DSSW, Scoggins, and DARS).
 Group sessions- This is one instructor and four clients. These classes will be offered in the evening and on
weekends. There are not available for clients that are paid by a service provider (DSSW, Scoggins, DARS).
 Over 21 Club/Recreational Therapy- This 2-hour “club” provides a small group social experience with activities
including horse care, horsemanship, and recreational therapy activities. Lessons are planned based on clients’
individual goals and objectives; to improve gross and fine motor skills, motor planning, balance, coordination,
flexibility, posture, muscle tone, sensory integration, communication and social skills.
 Equine Assisted Therapies- Commonly known as Hippotherapy is a physical, occupational and speech-language
treatment strategy that utilizes the movement of the horse to help achieve functional goals. This treatment
strategy can specifically address impairments of tone, range of motion, timing, attention, awareness,
coordination, balance, speech, and postural control.
 Speech Therapy
 Physical Therapy


ABA Therapy- Provided by a Board Certified Behavior Analyst who is also a PATH Int’l Certified Therapeutic
Riding Instructor. ABA benefits clients who struggle with behavioral issues and provides them an opportunity to
learn new skills. Through reinforcement provided by the horse, the client begins independent learning from
his/her horse. Limited availability.
Veterans Program- This program is for active duty service members and veterans partnering with horses and
veteran volunteers. The goal of this program is to improve the lives of servicemen and women who have
suffered injury in the line of duty, helping them adjust physically and emotionally to their post-combat lives.
Active duty service members and veterans with a diagnosis of PTSD, TBI, amputations, burns, and neurological
impairment may benefit from this service.
Is the client currently serving or has previously served in the United States Military or is a dependent of one?
Please circle one :
Yes
No
Name of Service Member: ___________________________________________________
Relationship to Client: _______________________________________________________
Status: Please circle one:
Active
Retired
Branch: ____________________________
Rank: __________________________
Page 2 of 12
R.O.C.K., Ride On Center for Kids
PO Box 2422 Georgetown, TX 78627
2050 Rockride Lane, Georgetown, TX 78626
(512) 930-7625 office
(512) 863-9231 fax
www.rockride.org
Program Overview (continued)

School Based program- The Instructors and volunteers bring together academics with Equine Facilitated
Learning, social skills, sensory regulation, and cognitive behavior therapy. This is a fun and exciting way to
reinforce social, behavioral and academic skills. Specially trained volunteers offer role modeling, mentoring and
social opportunities for the students that they may not otherwise receive.
Benefits of Equine Assisted Activities and Therapies May Include:












Improving muscle tone and coordination
Improving gross and fine motor skills
Experiencing the 3-dimensional movement of the horse, which is similar to a person’s normal walking gait, and
cannot be duplicated in a clinical setting.
Enhancing balance and posture
Stimulating the cardiovascular system and promoting wellness
Building self-esteem and confidence
Developing a meaningful relationship with the volunteers and the horse
Channeling aggressive or hyperactive behavior and developing sequencing abilities
Improving memory and organizational skills
Improving ability to perform activities of daily living
Improving Communication skills
Improving problem solving skills
How R.O.C.K is Organized:
R.O.C.K. is a non-profit 501 (c) (3) center governed by a volunteer Board of Directors
and is organized into strategic plan implementations teams. Some of the team leaders are paid employees, while some
are volunteers. We rely on private and corporate donations, grants, proceeds from special events and client tuition. All
instructors at R.O.C.K. are certified by PATH International. Volunteer Horse Handlers and Side Walkers are trained in
specific methods to help provide our clients with the most beneficial experience possible.
Page 3 of 12
R.O.C.K., Ride On Center for Kids
PO Box 2422 Georgetown, TX 78627
2050 Rockride Lane, Georgetown, TX 78626
(512) 930-7625 office
(512) 863-9231 fax
www.rockride.org
Client Guidelines
This page contains important information about the policies and procedures of R.O.C.K. Please keep it handy to refer
to when needed.
Sessions: R.O.C.K. begins regular sessions in September and ends in June. Breaks and holidays are included. We closely
follow the GISD calendar for most holidays and for weather issues.
New Client Registration: New clients will be screened by a ROCK therapist or instructor before being accepted into the
program. Upon receipt of all required paperwork, you will be contacted to schedule a screening. Acceptance into the
program is always dependent upon the availability of volunteers, appropriate horses, safety precautions and
contraindications.
Tuition/Fees:
Screening Fees- $35….a one-time fee paid at the time of initial screening
Administration fee- $25…a yearly fee due from ALL clients by your first day of attendance each year
Therapy sessions (PT, ST) fee- $85 per therapy session
Therapeutic Horsemanship:
 Private- $65 per session
 Semi-Private- $55 per session
 Group- $50 per session
 ABA- $65 per session
R.O.C.K. appreciates (and depends on!) tuition being paid in a timely manner, therefore we have the following payment
policy:
 R.O.C.K. requires a deposit that is equal to your first month’s tuition due after your registration is confirmed, no
later than September 1. This deposit will be applied to your July invoice (or upon withdrawal).
 Clients are billed at the beginning of each month for services rendered the previous month. Payment is due
upon receipt and considered late if received after the 15th of the month.
 If a client becomes 2 months behind in payments, they have until the 15th of the next month to pay the total
balance due or they will be withdrawn from the program. Their riding session will be offered to someone on the
waiting list.
 If at any time during the yearly session they are able to pay the total balance due AND their riding spot has not
been filled, they may re-enter the program.
 A client who is withdrawn from the program for financial reasons will be placed on the waiting list above clients
who have not yet joined the program. They must pay the total balance due before returning to the program.
 If a client is having difficulty staying current on payments, they are encouraged to apply for help from the
scholarship fund.
 If you have an outstanding balance, it must be paid in full before the client can apply for horse shows, summer
camp, or for the following year’s session.
Page 4 of 12
R.O.C.K., Ride On Center for Kids
PO Box 2422 Georgetown, TX 78627
2050 Rockride Lane, Georgetown, TX 78626
(512) 930-7625 office
(512) 863-9231 fax
www.rockride.org
Client Guidelines (continued)
If you need to discuss financial issues, please contact Sheri Ruther, Business Operations Manager, sheri@rockride.org
Tuition/fees are payable to R.O.C.K. by cash, check, or credit card. Payments can be placed in the gray box on the wall in
the Welcome Center or mailed to R.O.C.K
P.O. Box 2422
Georgetown, Texas 78627
Class Cancellations: The R.O.C.K. instructors/therapists, make every attempt to provide services, even in inclement
weather. Sometimes, if riding is not possible, un-mounted lessons may be given. Classes will only be canceled in the
event of dangerous or threatening weather. Your instructor will call the number you have designated to inform you of
class cancellations or you may call the office. You will not be charged for classes cancelled by R.O.C.K.; however, if you
cancel with less than 24 hour notice or do not come for a session there will be a $25 charge.
If your tuition is paid by a service provider (DSSW, Scoggins, DARS etc.) R.O.C.K. can only bill for days that you receive
services. Therefore, to keep things fair for all clients, if you cancel the session, you will be charged a cancellation fee of
$25. If the sessions are cancelled by R.O.C.K., no fee will be charged.
Paperwork: The following paperwork is required for all clients and must be renewed annually during June and July
regardless of when you enter the program
1. Registration/Release/Authorization for Emergency Medical Treatment
2. Client Goals/Skills/Health History
3. Client Medical History and Physician’s Statement: to be filled out and signed by physician
4. Prescription for Physical or Speech Therapy: to be filled out and signed by a physician for hippotherapy clients
only
5. R.O.C.K. Schedule Request
Attendance: When you register and are accepted into the program, volunteers, horses and staff are assigned and look
forward to working with you each week. If you are unable to make your class time, please give us at least 24 hours
notice. If you know of last minute cancellations, call your instructor or the R.O.C.K. office at 512-930-7625. When a
client does not show up for his/her session, volunteers who were assigned to work with them become discouraged and
may drop out. This jeopardizes the entire program. Three absences without notice may result in being dropped from
the schedule.
Illness: We want to keep everyone healthy; therefore, the client should not attend unless he/she has been fever-free
with no vomiting or diarrhea for 24 hours.
Medical Leave: Medical leave may be applied to clients who are absent due to a hospital stay or a significant medical
issue. The instructor/therapist will determine, on a case by case basis, if the absences are considered “Medical Leave”.
Common illness and doctor’s appointments are not considered Medical Leave. Clients may have up to 4 consecutive
absences for medical leave during the year without losing their place in the riding schedule or being charged a class
cancellation fee.
Page 5 of 12
R.O.C.K., Ride On Center for Kids
PO Box 2422 Georgetown, TX 78627
2050 Rockride Lane, Georgetown, TX 78626
(512) 930-7625 office
(512) 863-9231 fax
www.rockride.org
Client Guidelines (continued)
Long Term Medical Leave: Long Term Medical Leave is when a client is on medical leave for more than four (4)
consecutive classes. After the 4th absence, the client is offered 2 options:
Option 1. The client may request “Medical Tuition Assistance” to hold their spot in the riding schedule. This
means that the client is responsible for paying half of the tuition amount for each class missed over four (4).
Option 2. The client may choose to give up their riding spot for the rest of the year so it can be offered to
someone on the waiting list. If they choose to give up their spot but plan to return to the program within the
year, they are placed at the top of the waiting list.
Clothing Requirements for Clients: If you choose to have your own helmet, it needs to be an ASTM/SEI approved
helmet and cannot exceed more than 5 years past the manufactures date: Please see your instructor/therapist with any
questions.
 Long pants or appropriate clothes for your class or the weather (Shorts may be worn when it is hot). Please do
not wear jeans with bling on the pockets-the bling tears up our leather saddles. Jeans should be comfortable to
ride in-not too loose and not too tight.
 Closed toe shoes or boots
 Sunscreen, gloves, or jacket, as needed.
Weight Guidelines: Maximum weight for riders is 200 lbs. to provide for the safety and comfort of our clients,
volunteers and horses.
Punctuality: It is important for a client to arrive approximately 10-15 minutes prior to the scheduled class time in order
to sign-in, check bulletin boards for announcements, put on your helmet and greet everyone.
Late Rider Policy: If a client is late for their scheduled session time, R.O.C.K. cannot guarantee he/she will be able to
ride. Once the session has begun, the instructor/therapist may not be able to leave the other riders to mount late
arriving students. Horses will be untacked and volunteers released 15 minutes after the scheduled start time of the
class.
Weight Limitations: Client plus tack should not exceed 20% of the horse’s weight. (Example: A client that weighs 180
lbs. using a saddle that weighs 20lbs should ride a horse whose weight is greater than 1000 lbs.)
Siblings: If siblings are in attendance with parents of clients participating in class, parents are responsible for the direct
supervision of these children at all times. Noise and lots of activity can distract riders and horses.
Conduct at the Center: It is mandatory that everyone complies with all posted safety rules and abides by all posted offlimit areas. R.O.C.K. is a no smoking facility and the use of drugs or alcohol on the property is strictly forbidden. No
mistreatment, abuse, or suggested abuse of any person or animal will be tolerated. For the safety and respect of others,
NO weapons of any kind are permitted on the premises. We reserve the right to ask anyone to leave the premises.
Page 6 of 12
R.O.C.K., Ride On Center for Kids
PO Box 2422 Georgetown, TX 78627
2050 Rockride Lane, Georgetown, TX 78626
(512) 930-7625 office (512) 863-9231 fax
www.rockride.org
CLIENT REGISTRATION/AUTHORZATION FOR
EMERGENCY MEDICAL TREATMENT
(Please print legibly)
First Name: ____________________________ Last Name: ______________________ MI: __________
Date of Birth_____/______/__________
Gender: F M
Name of Parents/Legal Guardian: ______________________________ Home Phone: (____)______________________
Client/Parent Cell: (_____) ___________________________ Work: (_______)___________________________
Other Parent Cell: (_______) ______________________ Work: (________) ______________________________
Please (*) the phone number above we should call to inform you of class cancellations.
Address to use for correspondence from R.O.C.K. _____________________________________________
City_____________________________ State___________ Zip_________________ County__________
E-mail address to use for correspondence from R.O.C.K._______________________________________
Employer/Occupation (parent of client):_________________________________________________
Caregiver (if applicable):______________________________________Phone: (_______) ____________
School/Employer (of client) ______________________________________________________________
Preferred Medical Facility: _______________________________ Allergies: ________________________
Current Medications & Dosage: __________________________________________________________
In the event of an emergency, contact:
Name: _______________________ Relation: ___________________ Phone :(_____) _______________
Name: _______________________ Relation: ___________________Phone :(_____) ________________
Referral Source: How did you hear about us: _________________________________________________
Referring Physician/clinic, /agency: _________________________________________________________
Phone number (_____) ______________________
Fax number: (_____) _____________________
Page 7 of 12
R.O.C.K., Ride On Center for Kids
PO Box 2422 Georgetown, TX 78627
2050 Rockride Lane, Georgetown, TX 78626
(512) 930-7625 office (512) 863-9231 fax
www.rockride.org
CLIENT REGISTRATION/RELEASE &
AUTHORIZATION FOR EMERGENCY
MEDICAL TREATMENT (continued)
Client Name: _____________________________________________________________________
Read both and check one below and sign:
 Consent Plan
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 R.O.C.K. to 1) Secure and retain medical treatment
and transportation if needed. 2) Release any records upon request to the authorized individual or agency involved in
the medical emergency treatment. 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 emergency
contacts are unable to be reached.
Consent Signature: _____________________________________ Date: __________________________
(Client, Parent, or Legal Guardian)

Non-Consent Plan
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process
of receiving services or while being on the property of the agency. In the event emergency treatment/aid is
required, I wish the following procedures to be followed:
_________________________________________________________________________
Non-Consent Signature: ______________________________ Date: _______________________
(Client, Parent, or Legal Guardian)
Billing Information- Please check appropriate boxes, provide additional information, if necessary, and sign and
date.





Billing email address if different than the one on previous page. Statements are emailed out monthly via a
secure email. _____________________________________________________
I do not have an email address. Please mail invoices to_______________________________
Private pay clients: I understand that I will be charged my regular class tuition fee if I cancel or do not show up
for a lesson/session. There will be no charge for classes cancelled by R.O.C.K.
Service Provider Client: My tuition is paid by _________________________. I understand that if I cancel or do
not come for a lesson/session, I will be charged a class cancellation fee of $25. There will be no charge for
classes cancelled by R.O.C.K.
I have read and agree to abide by all R.O.C.K. guidelines and policies included in this packet.
_________________________________________________ _____________________________
Client/Parent/Guardian Signature
Date
Page 8 of 12
R.O.C.K., Ride On Center for Kids
PO Box 2422 Georgetown, TX 78627
2050 Rockride Lane, Georgetown, TX 78626
(512) 930-7625 office (512) 863-9231 fax
www.rockride.org
CLIENT REGISTRATION/RELEASE &
AUTHORIZATION FOR EMERGENCY
MEDICAL TREATMENT (continued)
Liability Release:
___________________________________ (Client’s name) would like to participate in the R.O.C.K. program. I
acknowledge the risks and potential risks of horseback riding. However, I feel that the possible benefits to
myself/son/daughter/ward are greater than the risk 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 R.O.C.K., its
Board of Directors, Instructors, Therapists, Aides, Horse Owners, Volunteers and /or Employees for any and all injuries
and/or losses I/my son/daughter/ward may sustain while participating in R.O.C.K. programs. WARNING-Under Texas law
(Chapter 87, Civil Practice and Remedies Code), an equine professional is not liable for an injury to or the death of a
participant in equine activities resulting from the inherent risks of equine activities.
Signature: _______________________________________ Date: _____________________________
Client, Parent, Legal Guardian
PHOTO RELEASE:
I hereby (Circle one) Consent
Do NOT Consent
To the use and reproduction by R.O.C.K. of any and all photographs and any other audio/visual materials taken of
me/my son/daughter/ward for promotional printed material, educational activities. Exhibitions or for any other use for
the benefit of the program.
Signature: _____________________________________ Date: _____________________________
Client, Parent, Legal Guardian
This above releases apply to all family members & caregivers of this client. Contact your instructor if you have any
questions about this policy
Page 9 of 12
R.O.C.K., Ride On Center for Kids
PO Box 2422 Georgetown, TX 78627
2050 Rockride Lane, Georgetown, TX 78626
(512) 930-7625 office (512) 863-9231 fax
www.rockride.org
Client Goals/Skills/Health History
To be completed by the client or parent/legal guardian.
_____________________________________
Client Name
_______________________
Date
Diagnosis: ________________________________________Date of onset:______________________________________
Goals (i.e. Why are you applying for participation? What would you like to accomplish?):__________________________
__________________________________________________________________________________________________
Medications (include prescription and over the counter: name, dose and frequency): _____________________________
__________________________________________________________________________________________________
Health History (include any changes in the past year for returning clients) ______________________________________
__________________________________________________________________________________________________
Describe your/your child’s abilities/difficulties in the following areas (including assistance required or equipment
needed):
Physical Function (i.e. Mobility skills such as transfers, walking, wheelchair use):_________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Psycho/Social Function (i.e. work/school including grade completed, leisure interest, relationships-family structure,
support systems, companion animals, fears/concerns, etc.):_________________________________________________
__________________________________________________________________________________________________
Communication Function:_____________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________
Client/parent/legal guardian signature
____________________________________________________
Date
For office use only: Date all completed paperwork rcvd: _________ Eval Date: ______________ Eval by: _______
Date eval fee rcvd: ________ Tuition Rate; _________ SF enter date: __________ by: _____________
Day and time of session: _________________________
Page 10 of 12
R.O.C.K., Ride On Center for Kids
PO Box 2422 Georgetown, TX 78627
2050 Rockride Lane, Georgetown, TX 78626
(512) 930-7625 office (512) 863-9231 fax
www.rockride.org
Physician’s Prescription for Physical and/or Speech Therapy
(Not required for Therapeutic Horsemanship)
Client’s Name:
Phone:
This is a prescription, for evaluation and treatment by a Physical Therapist or Speech Language Pathologist.
Recommended Frequency: 1 X per week OR as noted by physician here ________________________________
Precautions:
Physician’s Signature:
Date:
Please print, type or stamp
Physician’s Name:
Address:
E-mail:
Phone:
Fax:
Please note that the following conditions may suggest precautions and/or contraindications to equine assisted therapy.
Therefore, when completing this form, please note whether these conditions are present and to what degree.
Orthopedic
Medical/Psychological
Amputation
Medications – i.e., photosensitivity /Allergies
Atlanto-Axial Instability –
Animal Abuse
includes neurologic symptoms
Physical/Sexual/Emotional Abuse
Coxa Arthrosis
Blood Pressure Control
Cranial Deficits
Dangerous to self or others
Heterotopic Ossification/Myositis Ossificans
Exacerbations of medical conditions
Joint subluxation/dislocation
Fire Settings
Osteoporosis
Heart Conditions
Pathologic Fractures
Hemophilia
Spinal Fusion/Fixation
Medical Instability
Migraines
Post Traumatic Stress Disorder
PVD
Spinal Instability Abnormalities
Neurologic
Respiratory Compromise
Recent Surgeries
Hydrocephalus/Shunt
Substance Abuse
Seizure
Thought Control Disorders
Spina Bifida: Chiari II Malformation
Tethered Cord
Hydromyelia
Indwelling Catheters
Poor Endurance
Skin Breakdown
**See Explanation of Services and Fees on Pages 2 through 4 to help determine what services to request.
Page 11 of 12
R.O.C.K., Ride On Center for Kids
PO Box 2422 Georgetown, TX 78627
2050 Rockride Lane, Georgetown, TX 78626
(512) 930-7625 office (512) 863-9231 fax
www.rockride.org
Client Medical History & Physician’s Statement
Client’s Name: ________________________________ DOB: ________ Height: _________ Weight: ________
Diagnosis: ________________________________________________ Date of onset: ____________________
Medications: _______________________________________________________________________________
Seizure Type: __________________________ Controlled:
Shunt Present:
Y
N
Y
N
Date of Last Seizure: ________________
Date of last revision: _________________________________________________
Special Precautions/Needs: ____________________________________________________________________
Mobility: Independent Ambulation
Y
N
Assisted Ambulation
Y
N
+
-
Wheelchair
Y
N
For those with Down Syndrome:
Atlanto-Dens Interval x-rays:
Date: ______________
Result:
Neurologic Symptoms of Atlanto-Axial Instability: _________________________________________________
Please indicate current or past difficulties in the following systems/areas, including surgeries:
Yes No
Comments
Auditory
Visual
Tactile Sensation
Speech
Cardiac
Circulatory
Integumentary/Skin
Immunity
Pulmonary
Neurological
Muscular
Balance
Orthopedic
Allergies
Learning Disability
Cognitive
Emotional/Psychological
Pain
Other
Physician’s Statement
To my knowledge, there is no reason why this person cannot participate in supervised equestrian activities. However, I
understand that the therapeutic riding center will weigh the medical information above against the existing precautions
and contraindications. I concur with an evaluation and treatment of this person’s abilities/limitations by a
licensed/credentialed health professional (e.g., PT, OT, SLP, LCSW, etc.) in the implementations of an effective
equestrian program.
Physician’s Signature:
________________________ Date:
_____________
Please print, type or stamp
Physician’s Name:
Address:
Phone:___________________________________________ Fax:___________________________________________
E-mail:
Page 12 of 12