Dream Horse AZ
Dear New Client,
Enclosed, please find paperwork regarding your involvement with the Dream Horse AZ
Equine Assisted Therapy program. This set of forms will provide Dream Horse AZ with
information and history, as well as permission for Dream Horse AZ to work with you.
This information will be kept confidential.
Some general considerations:
Please remember to wear proper clothing and footwear – closed shoes such as boots or
sneakers, shorts, jeans or pants, and jacket if appropriate for the temperature - that can get
dirty/dusty. For your safety, please do not wear not wear loose jewelry (bracelets,
earrings, etc) that could become caught. Sun block should be worn in the Arizona sun and
it is mandatory to bring water to summer sessions. Dream Horse AZ is not responsible for
any of your belongings left at the barn.
To guard the privacy of our clients we ask that you not visit the farm without an
appointment. If you would like to bring family or friends to meet the horses you may do
so, but need to schedule a time with Dream Horse AZ so that a staff member can be
present and that no other private sessions are interrupted.
You may contact:
Jeff Cook, Executive Director (520) 460-8474, Dreamhorseaz@hotmail.com
We look forward to working with you. Please let us know if we can provide any
additional information or answer any questions.
Sincerely,
Jeff Cook
Jeff Cook
Executive Director
Dream Horse AZ Equine Therapy
(520) 460-8474
Dream Horse AZ – Adult Release Form
**Private and Confidential**
Page 1
Dream Horse AZ
Medical History and Release
Name:_________________________________________ Date of Birth:_____________
Address_________________________________________________________________
City, State, Zip ___________________________________________________________
Phone (H)____________________ (W)___________________ (C) ________________
Height:____________ Weight:_____________
Tetanus Shot: Y[ ] N[ ]
1. Emergency Contact Name/Number: __________________________________
2. Emergency Contact Name/Number: __________________________________
Medications (Please list names, dosages, side effects. Please state whether the
medication impacts balance, sensitivity to sunlight, etc. Please list medicines that you
take on a regular basis or have with you first.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Please check any areas of medical concern. Please explain in the Comments section
Areas
Comments
Auditory _________________________________________________________
Visual ___________________________________________________________
Speech ___________________________________________________________
Dream Horse AZ – Adult Release Form
**Private and Confidential**
Page 2
Cardiac ___________________________________________________________
Circulatory ________________________________________________________
Pulmonary ________________________________________________________
Neurological _______________________________________________________
Have you ever had a seizure disorder?_____________________________
Muscular _________________________________________________________
Orthopedic_________________________________________________________
Allergies / Asthma __________________________________________________
Allergies to hay _______ bee stings_____ dust _______ mold _______
Do you carry an epi pen? _______
Learning Challenges ________________________________________________
Psychological Impairment ____________________________________________
Diabetes __________________________________________________________
Other_____________________________________________________________
By signing this form, I, ___________________________________________________
(please print name) certify all information to be complete and true to the best of my
knowledge.
Signature:_______________________________________________________________
Date___/___/___
Comments: ______________________________________________________________
Dream Horse AZ – Adult Release Form
**Private and Confidential**
Page 3
Dream Horse AZ
Permission Slip
PHOTO RELEASE: I hereby consent to and authorize the use and reproduction by
Dream Horse AZ of any and all photographs and any other audiovisual materials taken of
me/my child/my ward for promotional printed material, educational activities,
exhibitions, or for any other use for the benefit of the program.
________DECLINE
LIABILITY RELEASE:
I acknowledge the risks and potential risks of interacting with horses. However, I feel the
possible benefits to my family or the child I care for 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 Dream Horse
AZ, its board of directors, instructors, therapists, volunteers and/or Employees for any
and all injuries and/or losses I may sustain as a result of use of Dream Horse AZ
property, equipment, or facilities while participating.
EMERGENCY RELEASE: In the event emergency medical aid/treatment is required due
to illness or injury while participating, I authorize Dream Horse AZ 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. This authorization includes x-rays, surgery,
hospitalization, medication and any treatment deemed “life saving” by the physician.
This provision will only be invoked if the parent/guardian or emergency contact person
listed cannot be reached.
WARNING -Under Arizona law, A signed release acknowledges that the person is aware of
the inherent risks associated with equine activities, is willing and able to accept full
responsibilities for his own safety and welfare and releases the equine owner or agent from
liability unless the equine owner or agent is grossly negligent or commits willful, wanton or
intentional acts or omissions.
I have read the above releases, and am willing child to participate in the Dream Horse AZ
Equine Assisted Learning program. Further I give Photo, Liability, and Emergency Consent,
as described above:
Signature _______________________________________________ Date___/___/___
Print Name______________________________________________________________
Dream Horse AZ – Adult Release Form
**Private and Confidential**
Page 4