617 Sunbird Lane, Berthoud CO, 80513
Registration: Therapeutic Riding and Farm Experience
Participant’s Name: ___________________ Female / Male DOB: ______ Weight_____
** For the safety of our horses and volunteers, Hands on Horses has a rider weight restriction of 180 pounds **
Parent/Guardian Name: ______________________________________________
Address:
______________________________________________________
______________________________________________________
Phone #s: Home:____________ Cell:______________ Work:_______________
Email:_____________________
Emergency Contact: ________________ Home: __________ Cell:_________
How did you hear about us? ________________________
X
Class
Date/Times:
Fee
Therapeutic Riding: Private Lesson
Call to Schedule
$50
Therapeutic Farm: Private Lesson
Call to Schedule
$40
Please make sure rider comes with closed toe shoes and pants. Please see our policy section for appropriate
attire. Please send your rider with water and sunscreen in the warmer months.
Payment is due at the time of registration. All paperwork must be completed prior to first lesson.
Please mail registration to:
Hands on Horses ATTEN: Julie Cody, 617 Sunbird Lane, Berthoud, and C0, 80513
Or email form to nlinke@hands-onhorses.com and complete payment online.
www.hands-onhorses.com
617 Sunbird Lane Berthoud, CO 80513
ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY
I [PRINT NAME HERE] ___________________________ (hereafter, "Participant", which term
includes Participant’s parent or legally-appointed Guardian, if a minor), freely and voluntarily seek
to participate in any or all programs, events and/or activities sanctioned, produced, or sponsored
by Julie Cody, Nicole Linke and Sandy Ross; Hands on Horses LLC and Brent Cody that include
but are not limited to equine lessons, training, educational and training programs, youth
programs, clinics/camps, therapeutic riding, therapy, and/or working around horses and other
animals on the premises.
These activities, programs, and events will hereafter be referred to as “the Activities,” and Hands
on Horses LLC and Painted Sky Riding LLC; together with its owners, officers, members,
employees, volunteers, instructors, independent contractors, and designated officials will
collectively be referred to as "Stables.”
In consideration of the Stables allowing the Participant to participate in the Activities, now and in
the future, Participant agrees as follows:
1. Participant Agreement. Participant agrees that he/she is responsible for his/her own safety
during lessons, training sessions, and general exposure to horses, and understands that
participation in horseback riding activities and training will expose him/her to above normal risks.
Participant agrees to abide by all instructions provided by Stables instructors, owners,
independent contractors, professionals, volunteers, and designated representatives during any
Activities. Participant agrees to wear appropriate attire on and around the horses including riding
helmet and appropriate footwear and attire.
2. Acknowledgment of Inherent Risks of Equine Activities/Assumption of Risks. Participant
acknowledges that there are numerous inherent risks of equine activities, whether preparing for,
entering, attending, participating in, or leaving the Stables and Activities. The inherent risks
include those dangers and conditions which are an integral part of equine activities, including, but
not limited to: (a) the propensity of an equine or other animal to behave in ways that may result in
injury, harm, or death to persons on or around them; (b) the unpredictability of the equine’s
reaction to such things as sounds, sudden movements and unfamiliar objects, persons or other
animals; (c) certain hazards such as surface or subsurface conditions; (d) collisions with other
animals or objects; (e) the potential of a participant or other Participant to act in a negligent
manner that may contribute to injury to the participant, Participant, or others, such as failing to
maintain control over the equine or not acting within his or her ability; (f) the breakage or failure of
tack or other equipment; and (g) the potential that an equine or animal may cause injury, harm, or
death to the rider or other persons or animals in the vicinity. Participant is not relying on Stables
to list within this document all possible inherent risks or all risks of participating in any of the
Activities at any location.
2. Waiver and Release of Liability. With full knowledge and appreciation of these and other
inherent risks associated with equine activities and the Activities, Participant freely and voluntarily
assumes the risks of the any activities involved in. In this connection, Participant also voluntarily
agrees to waive any and all rights to sue and hereby releases the Stables from all liability, loss,
claims, or actions for injury, death, expenses, or damage to person or property resulting from the
inherent risks of the Activities, or resulting from any action or inaction by the Stables. This waiver
and release is effective even if the injury, death or damage to person or property is caused by, or
contributed by, actions or failure to act of the Stables and which actions or inactions constitute
ordinary negligence or a violation of any applicable law pertaining to equine activity liabilities.
Neither Participant nor Participant's representatives shall make any claim against, maintain an
action against, or recover from the Stables or its owners, officers, members, employees,
volunteers, instructors, independent contractors, designated officials, or others acting on their
behalf; for injury, loss, damage or death of the Participant, to the Participant’s horse, or to the
Participant’s personal property (regardless of negligence by the Stables or regardless of an
alleged violation of an applicable equine activity liability law).
3. Equine Liability Act. Should the Activities take place in a state with an equine activity liability
law, Participant acknowledges reading the applicable state warnings and/or provisions set forth
below.
COLORADO
WARNING Under Colorado Law, 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, pursuant
to section 13-21-119, Colorado Revised Statutes.
4. Miscellaneous. This document is intended to be as broad and inclusive as applicable state law
permits. If any clause conflicts with applicable law, only that clause will be void but the remainder
shall stay in full force and effect.
I HAVE READ THIS ASSUMPTION OF RISK, WAIVER AND RELEASE OF LIABILITY, I
UNDERSTAND THAT IT IS RELEASE OF CLAIMS AND THAT I AM ASSUMING RISKS
INHERENT TO MY PARTICIPATION, AND I AGREE TO BE FULLY BOUND BY ITS TERMS.
Signature of Participant
Print Name of Participant
Date
Date of Birth [If Participant is Under 18]
IF Participant IS UNDER 18 YEARS OF AGE:
________________________________________________________________________
Signature of Parent or Legally-Appointed Guardian
Date
________________________________________________________________________
Print Name of Parent or Legally-Appointed Guardian
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
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, I authorize the instructors, volunteers, and therapists at Hands on Horses to:
1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
Client’s Name: _______________________________________________ DOB: __________________
Parent/Guardian’s Name: ________________________________________Phone: _________________
Address: ___________________________________________________City/ZIP: _________________
Email Address: _______________________________________________________________________
In the event I cannot be reached, contact:
Name: _______________________________________________________Phone: _________________
Name: _______________________________________________________Phone: _________________
Physician’s Name: _____________________________________________Phone: _________________
Preferred Medical Facility: ______________________________________________________________
Dentist’s Name: _______________________________________________Phone: __________________
Health Insurance Co.: __________________________________________Policy #: _________________
CONSENT PLAN
This authorization included x-ray, surgery, hospitalization, medication, and any treatment procedure
deemed “life saving” by the physician. This provision will only be involved if the person listed below is
unable to be reached.
Date: ___________________ Consent Signature: ____________________________________________
(parent, guardian, client)
Print Name: ___________________________________________________Phone: _________________
Address: _________________________________________________ City/Zip: ____________________
NON-CONSENT PLAN
I do not give my consent for emergency medical treatment/aid in case of illness or injury during the process
of receiving services or while being on the property. In the event emergency treatment/aid is required, I
wish the following procedures to take place:
Date: __________________ Non-Consent Signature: ___________________________________________
Print Name: __________________________________________________Phone: ____________________
Address: _________________________________________________ City/Zip: _____________________
THERAPEUTIC RIDING
Participant Name________________________________ Date:_______________
Medical History:
Diagnosis:_______________________________________________________________
Height: ____________________ Weight: __________________________
Past Surgeries (include
dates):________________________________________________
Current Medications: (Please note any possible side effects)
________________________________________________________________________
________________________________________________________________________
Seizures?_____________Type:______________________________________________
_
Allergies?_______________________________________________________________
_
Current treatment:
Please list other therapies currently receiving:
1) Speech and Language:
____________________________________________________________
Current Goals and Objectives:
________________________________________________________________________
________________________________________________________________________
2) Occupational:
_____________________________________________________________
Current Goals and Objectives:
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3) Physical:
_______________________________________________________________________
Current Goals and Objectives:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
(cont)
4) Psychological:
__________________________________________________________________
Current Goals and Objectives:
________________________________________________________________________
________________________________________________________________________
5) Other:
________________________________________________________________________
Current Goals and Objectives:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Family Goals at Hands on Horses:
In the following categories, what skills would you like to see developed while at Hands
on Horses? Goals will continue to be re-evaluated each session and as needed.
1) Social Skills:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2) Cognition:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3) Speech and Language:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4) Physical/Mobility:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
5) Strength/range of motion:
________________________________________________________________________
________________________________________________________________________
___________________________________________________________________
6) Emotional:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6) Sensory:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Additional Comments/Goals:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Dear Health Care Provider:
One of your patients is interested in participating in supervised equine activities. In order
to safely provide this service, Hands on Horses requests that you complete/update the
attached Medical History and Physician’s Statement. Please note that the following
conditions may suggest precautions and contraindications to equine activities.
Therefore, when completing this form, please note whether these conditions are present
and to what degree.
Orthopedic:
Atlantoaxial Instability - include neurological symptoms
Medical/Psychological:
Coxa Arthrosis
Cranial Deficits
Heterotrophic Ossification/Myositis Ossificans
Joint Subluxation/dislocation
Osteoporosis
Pathologic Fractures
Spinal Joint Fusion/Fixation
Spinal Joint Instability/Abnormalities conditions (i.e., RA, MS)
Animal Abuse
Allergies
Cardiac Condition
Physical/Sexual/Emotional Abuse
Blood Pressure
Dangerous to self or others
Neurological:
Hydrocephalus/Shunt
Seizure
Spina Bifida/Chiari II malformation/Tethered Cord/Hydromyelia
Migraines
PVD
Other:
Indwelling Catheters/Medical Equipment
Medications – i.e., photosensitivity
Poor Endurance
Skin Breakdown
Respiratory Compromise
Recent Surgeries
Hemophilia
Medical Instability
Thank you very much for your assistance. If you have any questions or concerns
regarding this patient’s participation in equine assisted activities, please feel free to
contact Hands on Horses at 720.371.3418 or nlinke@hands-onhorses.com
Rider’s Medical History & Physician’s Statement
Participant:_________________________
DOB: __________________
Height: ___________________________
Weight: ________________
Diagnosis: __________________________________________________________
______________________________________________________________________
Medications:____________________________________________________________
Seizure Type: __________________________
Controlled: Yes or No
Date of Last Seizure:_____________________
Special Precautions/Needs: _______________________________________
______________________________________________________________
Mobility: ______________________________________________________
For those with Down syndrome:
AtlantoDens Interval X-rays, date: _____________ Result
+
Neurological Symptoms or AtlantoAxial Instability: ______________________
Please indicate current or past special needs in the following system/areas, including surgeries:
Given the above diagnosis and medical information, this person is not medically
precluded from participation in equine assisted activities. I refer this person to Hands on
Horses for ongoing evaluation to determine eligibility for participation.
Physician Name/Title:____________________________________________
Signature: __________________________________
Date: __________
Address: ___________________________________
Phone:_________
Hands on Horses Policies and Procedures: Stable Copy
Non-Discrimination policy: Hands on Horses accepts participants and volunteers regardless of race, ethnic origin,
religion, etc.
Fees and Payment: Lessons are paid for by the session and must be paid in full at the time of registration to reserve
your spot. Refunds will not be available for missed classes. Prices are subject to change and are listed in the fee
schedule. If you will be missing one class in your session a prorated fee may be available.
If you wish to cancel your session/class after payment has been made you may due so before sessions begin.
Cancellations must be received one week before sessions begin to receive full payment refund. If cancellation occurs
after this time, Hands on Horses will reserve half the payment as a holding fee and you will be refunded the remainder
of your payment. No refunds will be made after sessions begin.
Cancellation Policy: If you are unable to make a scheduled class please provide notice by calling or texting (720)
371-3418 at least 24 hours prior to the class. Arriving 20 minutes or more late to a scheduled lesson will be considered
a no-show and the lesson will be canceled. Make-up sessions are available for group classes if there is availability in
another group class or by paying an additional $15 to schedule a private lesson. Private lessons must be rescheduled
within the same week.
If Hands on Horses needs to reschedule due to inclement weather notice will be provided to participants least 2 hours
prior to the scheduled class. A make-up class will be rescheduled for cancellations made by Hands on Horses. Weather
will rarely be a cause for cancellation, there are several unmounted activities that can help to improve the riders overall
understanding of horsemanship. Please come dressed appropriately.
Attire and Footwear: All riders are required to wear long pants such as jeans or riding breeches. Nylon or loose and/or
stretchy pants are unsuitable as they are slippery in the saddle and can get tangled. Riders performing trot and canter
work off lead are also required to wear smooth soled and heeled boots (heels must be at least ¼”). All riders must wear
an ASTM/SEI approved riding helmet while mounted. Hands on Horses will provide helmets.
Change of Health or Medication Status: Participants must inform Hands on Horses, in writing, immediately of any
changes in health status, conditions, and/or medications. This includes, but is not limited to changes in weight,
surgeries, revised diagnosis, etc.
Confidentiality: Any and all information pertaining to the participant of Hands on Horses therapeutic programs must
and will be respectfully held in strict confidence.
Driving and Parking: The speed limit on the grounds is 5mph. Please be alert for pedestrians and animals. Parking is
available in front of the barn and along the west fence line by the horse trailers. Please do not block any gate.
Safety and Conduct of Participants and Families:
-Participants are expected to arrive on time and dressed appropriately.
- Children not participating in a session must be supervised by an adult at all times.
-Appropriate behavior is expected of all visitors, including respectful treatment of people, animals and materials.
- Participants may not enter animal pens, corrals and/or fields until the instructor gives permission.
- No pets are allowed on the grounds.
-Smoking, alcohol, or illegal substances are not permitted on the property.
-Parents may view riding lessons from the seating area on the east side of the arena. Please keep noise and movement to a minimum to
avoid interruption of the class.
I have read and agree to the above Hands on Horses polices:
Hands on Horses Policies and Procedures
Non-Discrimination policy: Hands on Horses accepts participants and volunteers regardless of race, ethnic origin,
religion, etc.
Fees and Payment: Lessons are paid for by the session and must be paid in full at the time of registration to reserve
your spot. Refunds will not be available for missed classes. Prices are subject to change and are listed in the fee
schedule. If you will be missing one class in your session a prorated fee may be available.
If you wish to cancel your session/class after payment has been made you may due so before sessions begin.
Cancellations must be received one week before sessions begin to receive full payment refund. If cancellation occurs
after this time, Hands on Horses will reserve half the payment as a holding fee and you will be refunded the remainder
of your payment. No refunds will be made after sessions begin.
Cancellation Policy: If you are unable to make a scheduled class please provide notice by calling or texting (720)
371-3418 at least 24 hours prior to the class. Arriving 20 minutes or more late to a scheduled lesson will be considered
a no-show and the lesson will be canceled. Make-up sessions are available for group classes if there is availability in
another group class or by paying an additional $15 to schedule a private lesson. Private lessons must be rescheduled
within the same week.
If Hands on Horses needs to reschedule due to inclement weather notice will be provided to participants least 2 hours
prior to the scheduled class. A make-up class will be rescheduled for cancellations made by Hands on Horses. Weather
will rarely be a cause for cancellation, there are several unmounted activities that can help to improve the riders overall
understanding of horsemanship. Please come dressed appropriately.
Attire and Footwear: All riders are required to wear long pants such as jeans or riding breeches. Nylon or loose and/or
stretchy pants are unsuitable as they are slippery in the saddle and can get tangled. Riders performing trot and canter
work off lead are also required to wear smooth soled and heeled boots (heels must be at least ¼”). All riders must wear
an ASTM/SEI approved riding helmet while mounted. Hands on Horses will provide helmets.
Change of Health or Medication Status: Participants must inform Hands on Horses, in writing, immediately of any
changes in health status, conditions, and/or medications. This includes, but is not limited to changes in weight,
surgeries, revised diagnosis, etc.
Confidentiality: Any and all information pertaining to the participant of Hands on Horses therapeutic programs must
and will be respectfully held in strict confidence.
Driving and Parking: The speed limit on the grounds is 5mph. Please be alert for pedestrians and animals. Parking is
available in front of the barn and along the west fence line by the horse trailers. Please do not block any gate.
Safety and Conduct of Participants and Families:
-Participants are expected to arrive on time and dressed appropriately.
- Children not participating in a session must be supervised by an adult at all times.
-Appropriate behavior is expected of all visitors, including respectful treatment of people, animals and materials.
- Participants may not enter animal pens, corrals and/or fields until the instructor gives permission.
- No pets are allowed on the grounds.
-Smoking, alcohol, or illegal substances are not permitted on the property.
-Parents may view riding lessons from the seating area on the east side of the arena. Please keep noise and movement to a minimum to
avoid interruption of the class.
I have read and agree to the above Hands on Horses polices: