Dear Registered Instructor Workshop Host Site,

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Dream Catchers at the Cori Sikich Therapeutic Riding Center
10120 Fire Tower Road
Toano, VA 23168
hjolly@dreamcatcherswilliamsburg.org
www.dreamcatcherswilliamsburg.org
Dear OSWC Participant:
Thank you for your interest in attending the PATH INTERNATIONAL On-Site Workshop and/or Certification
for Registered Level Instructors from June 24 - 27, 2013, at Dream Catchers. We are pleased to offer the
certification to 10 participants, and the workshop for up to 20 participants.
Enclosed is the PATH INTERNATIONAL Phase Two packet along with paperwork needed for our center in
order for you to participate either as a workshop participant and/or a certification candidate. Please return all
enclosed paperwork, along with copies of your PATH INTERNATIONAL membership card, Instructor-inTraining letter, and your payment by check made payable to Dream Catchers ($450 for workshop only/$350
for certification only or both for $700 or an audit fee for the workshop of $125) no later than May 15, 2013.
However, please note that we will accept registrations from only 10 certification candidates and 20 workshop
participants, and after all spaces have been taken will maintain a waiting list. If you should cancel your
participation between May 16 and June 10, 2013, all but $100 to cover administrative costs will be refunded.
There will be no refunds issued after June 10, 2013.
Upon receipt of your payment and all completed forms and materials, you will receive a confirmation letter with
more details about the schedule during the workshop and certification.
If you are in need of lodging during your stay in Williamsburg, we will be happy to provide you with a list of
local hotels that are convenient to Dream Catchers.
If you have any questions, concerns or special needs, please do not hesitate to contact us at 757-566-1775 or at
hjolly@dreamcatcherswilliamsburg.org
We hope to see you soon!
Sincerely,
Harriet Jolly
Office Manager
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Phase Two Packet
Candidate Forms
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Welcome Candidate!
Welcome to the PATH International Registered Instructor On-Site Certification Program! We applaud your commitment to gaining
professional certification through this method of testing. Please make sure that you have previously completed Phase One of the
PATH International Certification process prior to proceeding to the certification. All components of Phase One and Phase Two will
need to be successfully completed before you can complete the certification.
Purpose of Certification
The purpose of this certification is to determine if the candidates possess adequate prior experience and sufficient skills to meet the
criteria that are delineated for the PATH INTERNATIONAL Registered Instructor Program. Please refer to the PATH
INTERNATIONAL Registered Instructor Application booklet for a listing of all criteria. During the certification process you will be
evaluated on your horsemanship and teaching ability. While the On-Site process is an effective certification method, this can also be a
stressful experience. The following is designed to provide information to help you arrive properly prepared to succeed and make this a
positive experience.
Workshop Portion
Throughout the workshop you will be provided with invaluable insight and teaching strategies from experienced professionals. The
workshop will also include hands-on activities including role playing and demonstrations on proper mounting and dismounting.
However, the workshop portion serves as an educational review of the criteria, but cannot and does not provide the sole education
necessary to pass the certification. You are required to bring those materials indicated in the on-line Instructor Self-Study: 1) posture
& alignment photo; 2) a sample lesson plan.
Being Physically Prepared
Remember that both the teaching and the riding segments require physical preparedness to complete. If you have any concerns
regarding your ability to pass any component of the certification, based on physical or mental limitations due to disability, injury or
medical condition, contact the Host Site representative or the PATH INTERNATIONAL office for an Accommodation. See Instructor
Certification Process for Exception to Application Requirements.
The Horsemanship Component of Certification
 The riding test will be done after the workshop is complete. The Host Site and the evaluators will decide the scheduling of
this portion. It will either be at the conclusion of the second day of the workshop or on the morning of the certification day.
 Candidates will be assigned horses that meet their riding style and requirements.
 If candidates have specific horse needs, they should inform the Host Site representative prior to the riding portion.
 Candidates will assist in the grooming and tacking of their mounts.
 Candidates will be evaluated on both the warm-up and the riding pattern.
The Lesson Component of Certification
 Lessons will be randomly assigned and will be scheduled at ½-hour intervals.
 The Host Site will provide each candidate with detailed Rider Profiles for two students the evening prior to the certification
lessons.
 The Lesson Plan should be developed based on the information provided in the Rider Profiles.
 Candidates will need to provide a Lesson Plan to the evaluators prior to the beginning of the lesson.
 Each lesson will be 20 minutes long. This must include mounts, lesson content to include teaching an equestrian skill and
dismounts.
 Candidates are responsible for ensuring that their horses, volunteers and arena are set up for the class. The Host Site
representative will identify volunteer needs. Candidates are responsible for checking with the Host Site representative to
determine how these needs will be met and to determine which equipment each rider typically uses.
 Every effort has been made by the Host Site to provide suitable riders, volunteers and horses; however, as in any therapeutic
riding program, there exists the possibility of last minute substitutions. In the event that a substitution is made, the Host Site
representative will provide the candidate with information specific to the change.
 At the conclusion of the lesson, the candidate will need to complete the evaluation portion of the Lesson Plan and return it to
the evaluators.
Evaluation of Candidates
Following the completion of the lesson component, the evaluators will meet to complete written reports on each candidate. This
process takes several hours to complete. Be prepared to stay late or to meet the following day for your performance review. Individual
evaluation sessions will be scheduled at 15-minute intervals to review results with each candidate. Remember that all evaluations will
be based on the criteria outlined for the PATH INTERNATIONAL Registered Instructor Certification Program.
Thank you for participating in the PATH International Instructor Workshop and/or On-Site Registered Certification. Good
luck and enjoy!
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PATH Int’l. Instructor Workshop and/or On-Site Registered Certification
Phase Two Workshop and/or Certification Form
Name: ______________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Phone: Daytime: (
Fax: (
) ___________________ Evening: (
) _____________________ Cell: (
) __________________________
) _______________________ Email: _______________________________________________________________
Workshop and/or Certification dates: _________________________ Location: ____________________________________________
Please register me for the following:
 Workshop only ($450)  Certification only($350)
 Both - Workshop & Certification ($700)
If you are participating in the Certification component, complete the following for the purposes of horse and tack selection.
For the riding demonstration portion of certification, please indicate the following:
Preferred seat:  English  Western
Height:___________ Weight: ___________
All participants of the Workshop and/or Certification must be PATH INTERNATIONAL Individual Members.
Please use the forms provided. Incomplete Phase Two packets will not be accepted.
To be completed by all participants:
 I am a current PATH INT’L Individual member and have included a copy of my card. Membership # (required) ____________
 I am not a current PATH INT’L Individual member and I have enclosed the $45.00 membership fee payable to PATH INT’L.
 I have enclosed my signed and dated PATH INT’L Liability Release and Emergency Medical Treatment Form.
 I am taking the workshop only and have enclosed the workshop fee of $450 (if applicable)
 I am enclosing the combined registration fee of $ 700 for both workshop and certification. (if applicable)
 I am auditing the workshop and am enclosing the audit fee of $ 125 (if applicable).
To be completed only by candidates applying for certification:
 I am participating in the certification only and I have enclosed the Registered Instructor On-Site-Certification fee of ________.
 I am at least 18 years of age.
 I have enclosed copies of my current CPR and First Aid certification.
 I have completed Phase One of the Certification process through the PATH INTERNATIONAL office.
 I have enclosed a copy of the Confirmation of Instructor-In-Training status letter from the PATH INTERNATIONAL office
verifying my successful completion of Phase One.
 I have applied for an exemption or accommodation through the PATH INTERNATIONAL office and have enclosed a copy of the
letter.
 I have enclosed the Documentation of Group Mounted Teaching Hours form.
 I have enclosed this Registration form.
 I have enclosed the Resume form.
 I have enclosed the Personal Reference form.
 I have enclosed the Professional Reference form.
 I have enclosed the Essay Questions form.
 I have completed a PATH INTERNATIONAL On-Site Workshop, or I will be attending the workshop scheduled with this
certification.
If a PATH INTERNATIONAL On-Site Workshop was previously attended, please indicate the date and
location:________________________ and include a copy of your Certificate.
 I understand that prior to the Workshop and/or Certification I will make a copy of all application materials to keep for my records.
 I understand that all components of the Certification process need to be completed before I can attend the certification.
Make Workshop and/or Certification checks payable to: Dream Catchers
Send to: Dream Catchers, 10120 Fire Tower Road, Toano, VA 23168
Certification Registration Deadline: May 15, 2013
Completed Phase Two Packet Deadline: June 7, 2013
All application materials will be kept confidential and used for no other purposes than that required for PATH INT’L Instructor Certification.
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PATH INT’L Instructor Workshop and/or On-Site Registered Certification
Applicant Riding Demonstration
In order to successfully pass this segment, all candidates must wear an ASTM/SEI approved helmet. Candidates will be required to demonstrate their
own riding ability by riding the following pattern, which includes:
- Warm-up
- Circle
- Ride at a walk, trot (jog), and canter (lope) both directions of the arena
- Back
- Change the rein through the diagonal
- Halt
After a brief warm-up, execute the following pattern to demonstrate your riding skills:
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PATH INT’L Instructor Workshop and/or On-Site Registered Certification
Riding Instructor Resume
Name: ______________________________________________________ Phone: _________________________
Address: ____________________________________________________________________________________
City: ______________________________________________ State: _______________ Zip: ________________
Are you a licensed therapist?
PT
OT
Other Therapist: ________________________________
Are you a PATH INTERNATIONAL Individual member:
Yes
No
If affiliated with an operating center, list name: _____________________________________________________
EDUCATION
High School: _______________________________________ Year: ________ Diploma: __________________
College or Vocational: _______________________________ Year: ________ Diploma: __________________
Other Studies/Certificates/License: ____________________________________ Year: _____________________
Work Experience related to disabilities (other than therapeutic riding): ___________________________________
___________________________________________________________________________________________
EQUESTRIAN BACKGROUND
Number of years riding: ________ Owning a horse: ________ Number of years giving riding instruction: ________
Type of instruction: _________________ Pony Club level: ______________ 4-H level: ____________________
Your equestrian experience: ____________________________________________________________________
___________________________________________________________________________________________
EXPERIENCE TEACHING RIDERS WITH DISABILITIES
Do you work with any of the following disabilities? Check all that apply.
Mental Impairments
Cerebral Palsy
Learning Disabilities
Multiple Sclerosis
Communication Impairment
Muscular Dystrophy
Hearing Impairments
Brain Injury/Head Trauma
Visual Impairments
Spina Bifida
Emotional Impairments
Stroke/CVA
Autism
Post-Polio
Down Syndrome
Other ____________________
ADDITIONAL INFORMATION
Professional organizations of which you are a member:_______________________________________________
___________________________________________________________________________________________
Articles/books/lectures you have done:____________________________________________________________
___________________________________________________________________________________________
Signature: __________________________________________________________________________________
Title: __________________________________________________ Date: _____________________________
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PATH INT’L Instructor Workshop and/or On-Site Registered Certification
Personal Reference
(This reference cannot be the same as the Professional Reference.)
Instructor Certification Candidate’s Name: _______________________________________________________
Name of Reference: __________________________________________________________ Age: __________
Address: _________________________________________________________________________________
City: __________________________________________________ State: _________ Zip: _______________
Phone: Day: ___________________________________ Evening: ________________________________
In what capacity does the reference know the candidate?
Evaluate the candidate’s knowledge of horses and horsemanship:
Evaluate the candidate’s understanding of individuals with disabilities and riding:
(Please attach extra sheets if necessary)
Signature of Reference: _______________________________________________ Date: ____________
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PATH INT’L Instructor Workshop and/or On-Site Registered Certification
Professional Reference
(This reference cannot be the same as the Personal Reference.
This reference must be familiar with applicant’s riding instruction experience.)
Instructor Certification Candidate’s Name: _______________________________________________________
Name of Reference: __________________________________________________________ Age: __________
Address: _________________________________________________________________________________
City: __________________________________________________ State: _________ Zip: _______________
Phone: Day: ___________________________________ Evening: ________________________________
In what capacity does the reference know the candidate?
How many hours of lesson instruction has the applicant completed?
Evaluate the candidate’s knowledge of horses and horsemanship:
Evaluate the candidate’s understanding of individuals with disabilities and riding:
(Please attach extra sheets if needed)
Signature of Reference: _______________________________________________ Date: ____________
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PATH INT’L Instructor Workshop and/or On-Site Registered Certification
Essay Questions
In your own words, answer the following questions. You may use this page or answer on a separate sheet of paper.
Typed answers are suggested, as they are the easiest to read.
Instructor Certification Candidate’s Name: _______________________________________________________
1.
Indicate which style of riding you teach:
_____Balance Seat
_____Forward Seat
_____Dressage
_____Western
_____ Other: ______________________________________________________
Explain why you teach the style of riding indicated and what the benefits are for your riders.
2.
Discuss your philosophy of teaching:
3.
Describe your strengths as a therapeutic riding instructor:
4.
Describe your opportunities for improvement as a therapeutic riding instructor:
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PATH INT’L Instructor Workshop and/or On-Site Registered Certification
Documentation of Mounted Group Lesson Teaching Hours
Name of Candidate: _________________________________________________________________________________
Address: __________________________________________________________________________________________
City: __________________________________________________State:_______________Zip:____________________
Phone: Day: (__ ) ______ Evening: (____)_______________ Email: _______________________________________
Date
Location/Organization
Discipline
Hours
Mentor’s NAME
&
PATH INTL ID#
Comments
Please note: This form is not valid without the Mentor’s PATH INT’L ID #
Total Hours: ________
Documentation of 25 hours teaching mounted group lessons to riders with disabilities. I do hereby affirm that that this
information recorded above is accurate and factual.
Candidate Signature: ______________________________________________________________ Date: ____________________
Please submit this form to the Host Site with your Phase Two packet.
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Registered Instructor On-Site Workshop and/or Certification
Authorization for Emergency Medical Treatment Form
In the event emergency medical aid/treatment is required due to illness or injury during the process of participating in the
PATH INTERNATIONAL Instructor Workshop and/or On-Site Registered Certification Program, or while being on the
property of the hosting PATH INTERNATIONAL Center, I authorize the PATH INTERNATIONAL Registered On-Site
Faculty/Evaluators to:
1. Secure and retain medical treatment and transportation if needed.
2. Release participant records upon request to the authorized individual or agency involved in the medical emergency
treatment.
Participant’s Name: _______________________________________________________________
Address: _______________________________________________________________
City/State/Zip: _______________________________________________________________
In the event that I cannot be reached, please contact:
Name: ____________________________ Phone: ________________ Relationship: __________
Name: ____________________________ Phone: ________________ Relationship: __________
Physician’s Name: ____________________________________Phone:_____________________
Preferred Medical Facility: ________________________________________________________
Health Insurance Company: ___________________________ Policy #:____________________
Consent Plan
This authorization includes x-ray, surgery, hospitalization, medication and any procedure deemed “life saving” by the
physician. This provision will only be invoked if the person listed below is unable to be reached.
Consent Signature: ____________________________________________ Date: ___________________
(Participant, Parent or Guardian)
Print Name: _____________________________________________ Phone: ______________________
Address: ____________________________________________________________________________
Non-Consent Plan
I do not give my permission for emergency medical treatment/aid in the case of illness or injury during the process of
participating in the PATH INTERNATIONAL Registered On-Site Certification process or while being on the property of
the hosting PATH INTERNATIONAL Center. In the event emergency treatment/aid is required, I wish the following
procedures to take place:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Consent Signature: ____________________________________________ Date: __________________
(Participant, Parent or Guardian)
Print Name: ____________________________________________ Phone: ______________________
Address: ____________________________________________________________________________
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PATH INT’L Instructor Workshop and/or On-Site Registered Certification
Liability Release Form
I, __________________________________________________, would like to participate in the PATH INT’L
(Candidate’s Name)
Instructor Workshop and/or On-Site Registered Certification. I acknowledge the risks and potential for risks of
horseback riding. However, I feel that the possible benefits to me 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 PATH INTERNATIONAL, it’s Board of Trustees, employees and
Faculty/Evaluators for any and all injuries and/or losses I may sustain while participating in the PATH
INTERNATIONAL Instructor Workshop and/or On-Site Registered Certification.
Signature: _____________________________________________ Date: _____________
(Candidate)
Many disabilities or injuries have accompanying conditions that pose special physical risks during exercise.
Horseback riding is exercise, as are other activities involved in this Workshop and/or Certification, such as
handling and working around horses. I understand that PATH INTERNATIONAL and the Host Site
recommends that I seek the advice of a physician before participating in activities that involve exercise, riding,
handling or being near horses.
I understand that if I have a disability/disabilities, injury or physical condition that might affect my ability to
ride, handle, or be around horses at the PATH INTERNATIONAL Instructor Workshop and/or On-Site
Registered Certification, I will need to apply for an exemption or accommodation as outlined in the
Accommodation or Exemption Policy.
Signature: _____________________________________________ Date: _____________
(Candidate)
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10120 Fire Tower Road
Toano, VA 23168
757-566-1775
OSWC Participant Information and Release
Name:
Date:
Address:
Day Phone:
City:
Zip:___________
DOB:_____________________
In case of emergency, please contact: Name:
Phone:
Relationship:
_______
Dates of On-Site Workshop and/or Certification:_____________________________
Media Release
Please check the appropriate box and sign below:
I hereby (please check one):
o
Consent to and authorize the use and reproduction by Dream Catchers at the Cori Sikich
Therapeutic Riding Center of any and all photographs and any other audio/visual media taken of me for
promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
o
Do not consent to above stated photo/media release.
Signature: _______________________________________ Date: ____________________
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Dream Catchers Emergency Medical Consent
Please check below the appropriate box and sign below:
o
I do hereby give consent to seek emergency medical attention in the event of a situation while on the premises or surrounding
premises of Dream Catchers at the Cori Sikich Therapeutic Riding Center located in Toano, Virginia, where it is deemed
necessary and prudent by the staff or volunteers of Dream Catchers to seek professional medical services. I expect my
emergency contact to be notified in the event that emergency medical care is sought on my behalf.
o
I do not give permission to the staff and volunteers of Dream Catchers at the Cori Sikich Therapeutic Riding Center to seek
emergency medical attention on my behalf. Instead, in the event of any emergency, I wish the following procedures to take
place (please explain in detail):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Printed Name:______________________________________________________
Signature: _________________________________________________________
Date: _____________________________________________________________
Release, Waiver & Indemnity Agreement
Desiring to utilize the premises known as the Cori Sikich Therapeutic Riding Center and the adjoining properties, I, as the
undersigned, do hereby willingly enter into this Release, Waiver & Indemnity Agreement.
I recognize that, under Virginia law, an equine activity sponsor or equine professional is not liable for an injury to or the death of an
individual in equine activities resulting exclusively from the inherent risks of equine activities. I fully understand that the activity of
mounting, riding, boarding, feeding, or even being near a horse, involves numerous dangers and risks of injury to said individual and I
completely release the owner of the Premises, and DCTR and its officers, directors, volunteers, employees, or its agents from any and
all liability for any and all injuries resulting from the Participant’s, Volunteer’s, or Staff’s engagement in the Programs offered by
DCTR.
I expressly agree that this Release, Waiver and Indemnity Agreement shall be governed and construed as being sufficient to satisfy the
assumption of risk and waiver requirements necessary to relieve equine activity sponsors and equine professionals from liability under
the Virginia Equine Activity Liability Act, Section 3.1-796.130, et.seq. of the Code of Virginia (the “Act”), and that the owners of the
Premises, DCTR and its officers, directors, volunteers, employees, and agents are covered as equine activity sponsors and/or equine
professionals by the provisions of this Act. This Release, Waiver, and Indemnity Agreement shall be governed and construed by the
laws of the Commonwealth of Virginia, regardless of where any injury or loss shall occur. In the event that any portion of this
Release, Waiver, and Indemnity Agreement shall be declared unenforceable, such declaration shall not affect the remaining terms of
this document, which shall survive intact.
Printed Name: _________________________________________________
Signature:_____________________________________________________
Date:_________________________________________________________
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Dream Catchers at the Cori Sikich Therapeutic Riding Center
Confidentiality Policy for Participants, Volunteers, and Staff
Maintaining confidentiality of medical and sensitive information is of utmost importance to
Dream Catchers. Participants and their families, other participants, volunteers and staff have a
right to privacy that gives them control over the dissemination of their medical or other
sensitive information. Dream Catchers staff, volunteers, and participants will preserve this right
of confidentiality for all individuals.
Dream Catchers staff, volunteers, PATH INTERNATIONAL certification and workshop
participants and activity participants will keep confidential all medical, social, referral, personal,
and financial information regarding a person and his/her family unless express permission to
share information is provided.
Anyone who works or volunteers for, or provides services to, Dream Catchers is bound by this
policy. Participants, their caregivers, and other family members must also preserve the
confidentiality of other participants and/or their family members. This includes, but is not
limited to, full, and part time staff, independent contractors, temporary employees, volunteers,
participants, family members and caregivers, visitors, workshop and certification participants,
and board members. In effect, this policy applies to anyone connected to Dream Catchers who
could obtain medical/sensitive participant information accidentally or purposely.
Disclosure of information to outside agencies or individuals requires the specific written
consent of the participant or if the participant is under the age of 18 or is deemed incompetent to
give authorization, then that participant’s parent, guardian or agent.
As a participant in a PATH INTERNATIONAL On-Site Workshop and/or Certification, I
hereby agree with the above stated written policy and agree to uphold its standards and
regulations.
_____________________________________
Signature of OSWC Participant
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Date
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