PARTICIPANT APPLICATION

Participant Application
General Contact Information
Participant - First Name *
Participant - Last Name *
Birth Date (mm/dd/yy) *
Gender Identity
Participant Phone Number (if >18)

Area Code Number
Participant Email (if >18)
example@example.com
Participant Address *

Street Address

Street Address Line 2

City Province

Postal Code
What county to you live in?

Bruce Dufferin Grey Simcoe Wellington York
Primary Contact - First Name *
Primary Contact - Last Name *
Primary Contact Type *
Primary Contact Phone *

Area Code Phone Number
Primary Contact Email *
example@example.com
Secondary Contact - First Name
Secondary Contact - Last Name
Secondary Contact Type
Secondary Contact Phone

Area Code Phone Number
Secondary Contact Email
example@example.com
Additional Contact - First Name
Additional Contact - Last Name
Additional Contact Type
Additional Contact Phone

Area Code Phone Number
Additional Contact Email
example@example.com
Billing Contact - First Name *
Billing Contact - Last Name *
Billing Contact Email *
example@example.com

Learning More About You
For sections that allow you to select multiple options:

PC - hold Command along with mouse/pad
MAC - hold Shift or Command along with mouse/pad
Height (inches) *
Weight (lbs) *
Weight restrictions exist for mounted programming
What school do you attend?
PRIMARY Diagnosis OR Social-Emotional Challenge *
ADDITIONAL Diagnoses AND/OR Social-Emotional Challenges
SELECT ALL THAT APPLY
Allergies
Current Medications
Additional Information
What programs are you interested in? *
SELECT ALL THAT APPLY
What are your goals for participating in programs? *
SELECT ALL THAT APPLY

Confidentiality and Information Release
I recognize that my role as a participant with Hope Haven Therapeutic Riding Centre will entitle me to certain information about other participants which should be treated as confidential. All information given to me by a parent/instructor/volunteer in relation to another participant will be discussed only with the personnel of Hope Haven and at no time will I discuss this information with any other individual. I recognize that all material and papers pertaining to a participant's care are legal documents, and that all information contained therein is confidential. If at any time there is a concern about the collection, use or disclosure of my personal information I may contact Hope Haven's privacy officer.

In order for everyone on the Hope Have team to create an empowering, fun and supportive environment it is important for all volunteers and staff to understand the needs of the participant. In recognition of this, I hereby authorize Hope Haven Therapeutic Riding Centre to release to its instructors and volunteers such information from these forms as may be necessary to conduct safe and beneficial programming. I recognize that all volunteers and staff have signed an oath of confidentiality.
Parent/Guardian Signature (or participant if >18) *

Confidentiality and Information Release Clear
Photo/Social Media Release
I hereby authorize Hope Haven Therapeutic Riding Centre to use and reproduce any photographs and/or other audio-visual materials taken of me for promotional printed material, educational activities, exhibitions or for any other use for the benefit of our programs. This may also include publishing on social media platforms such as Facebook, Instagram, and YouTube. *

YES NO

Acknowledgment of Risk & Release of Liability
Every individual must read and understand the following information before participating in equine activities.

To: Hope Haven Therapeutic Riding Centre and Family Camp Inc, their directors, employees, volunteers, business operators, and site property owners (all of them collectively called the HOST).

1. I Understand there are inherent DANGERS, HAZARDS and RISKS, (collectively called RISKS) associated with Equine Activities and injuries resulting from these "RISKS" are a common occurrence.

2. I Acknowledge that the Inherent "RISKS" of Equine Activities mean those DANGEROUS conditions which are an integral part of Equine Activities, including but not limited to:
- The propensity of any equine to behave in ways that might result in injury, harm or death to persons on or around them and to potentially collide with, bite or kick other animals, people or objects.
- The unpredictability of an equine's reaction to such things as sounds, sudden movement, tremors, vibrations, unfamiliar objects, persons or other animals and hazards such as subsurface objects.
- The potential for other participant(s) to act in a negligent manner that might contribute to injury to themselves or others, such as failing to act within their ability or to maintain control over an equine.
3. I Freely Accept and Fully Assume All Responsibility for the Inherent "RISKS" and the possibility of personal injury, death, property damage or loss resulting from my Participation in Equine Activities.

4. I Acknowledge that it remains my Sole Responsibility to act in such a manner as to be responsible for my own safety and to Participate Within My Own Limits.

5. In addition to consideration given for my Participate in Equine Activity, I and my heirs, executors, administrators and assigns (collectively called my "Legal Representatives") agree
- To Waive All Claims that I might have against the "HOST" ; and
- To Release the "HOST" from Any and All Liability for any loss, damages, injury, or expense that I or my "Legal Representatives' might suffer as a result of my Participation due to any cause whatsover including any negligence on the part of the "HOST" ; and
- To HOLD HARMLESS AND INDEMNIFY THE "HOST" from any and all liability for property damage or personal injury to any third party which might result from my Participation in Equine Activities.
In signing this form I understand all of the points above and I waive certain legal rights I or my "Legal Representatives" might have against the "HOST".
Signature (Acknowledgment of Risk & Release of Liability) *

Acknowledgment of Risk & Release of Liability Clear
Covid-19 Acknowledgement of Risk
As a participant or parent/guardian of the participant, I am aware of the risks of contracting Covid-19 while participating in face to face programming despite infection control measures taken by Hope Haven. I have considered the following list of factors that may put myself and/or my dependent at a higher risk of contracting Covid-19 and/or experiencing more severe symptoms, and freely accept and fully assume any such risks.
- Underlying respiratory or immune health condition for self or family member
- Difficulty maintaining required physical distancing due to cognitive impairment or need for physical assistance
- Unable or unwilling to comply with wearing a mask
- Frequent touching of face/mouth/nose or drooling
I have fully read and agree to follow all policies and procedures as outlined in Hope Haven’s Covid-19 Infection Control Policies document. I am aware that this document is continuously updated and available on Hope Haven’s website.

I am signing for myself and/or my dependent under my own free will and hereby release and agree to hold harmless Hope Haven, it’s Directors, Officers, employees, representatives and all individuals associated with my participation there from any and all claims or liabilities related to my attendance at Hope Haven.
Signature *

Covid-19 Acknowledgement of Risk Clear

Hope Haven Concussion Protocol & Code of Conduct

For Athletes and Parents/Guardians if
Hope Haven follows the policy and procedures as set by the Ontario Equestrian Concussion Guidelines. We also require a confirmation on a yearly basis, as determined by Rowan's Law, that all Hope Haven participants, parents/guardians as well as coaches and staff have reviewed the following:

1. Concussion Awareness Resources as provided by the Government of Ontario
2. Hope Haven's Concussion Code of Conduct

Hope Haven Code of Conduct

I will help prevent concussions by:
- Wearing the proper equipment for my sport and wearing it correctly (ASTM certified equestrian helmet).
- Developing my skills and strength so that I can participate to the best of my
  ability.
- Respecting the rules of my sport or activity.
- My commitment to fair play and respect for all* (respecting other athletes,
  coaches, team trainers and officials).
I will care for my health and safety by taking concussions seriously, and I
understand that:
- A concussion is a brain injury that can have both short and long-term effects.
- A blow to my head, face or neck, or a blow to the body that causes the brain to
  move around inside the skull may cause a concussion.
- I don’t need to lose consciousness to have had a concussion.
- I have a commitment to concussion recognition and reporting, including self
  reporting of possible concussion and reporting to a designated person when and
  individual suspects that another individual may have sustained a concussion.*
  (Meaning: If I think I might have a concussion I should stop participating in further
  training, practice or competition immediately, or tell an adult if I think another
  athlete has a concussion).
- Continuing to participate in further training, practice or competition with a
  possible concussion increases my risk of more severe, longer lasting symptoms,
  and increases my risk of other injuries.
I will not hide concussion symptoms. I will speak up for myself and others.
- I will not hide my symptoms. I will tell a coach, official, team trainer, parent or
  another adult I trust if I experience any symptoms of concussion.
- If someone else tells me about concussion symptoms, or I see signs they might
  have a concussion, I will tell a coach, official, team trainer, parent or another
  adult I trust so they can help.
- I understand that if I have a suspected concussion, I will be removed from sportand that I will not be able to return to training, practice or competition until I undergo a medical assessment by a medical doctor or nurse practitioner and have been medically cleared to return to training, practice or competition.
- I have a commitment to sharing any pertinent information regarding incidents of removal from sport with the athlete’s school and any other sport organization with which the athlete has registered* (Meaning: If I am diagnosed with a concussion, I understand that letting all of my other coaches and teachers know about my injury will help them support me while I recover.)
I will take the time I need to recover, because it is important for my health.
- I understand my commitment to supporting the return-to-sport process* (I will
  have to follow my sport organization’s Return-to-Sport Protocol).
- I understand I will have to be medically cleared by a medical doctor or nurse
  practitioner before returning to training, practice or competition.
- I will respect my coaches, team trainers, parents, health-care professionals, and
  medical doctors and nurse practitioners, regarding my health and safety.
By signing below, I acknowledge that:
1. I have fully reviewed and commit to the above HH Concussion Code of Conduct.
2. I have reviewed the Concussion Awareness Resources that I’m required to do yearly as determined by Rowan’s Law.
Signature *

Clear
Thank you for completing your Participant Application for Hope Haven. As soon as we receive and process your application we will be in touch!
SF ID
Should be Empty:

Participant Application

General Contact Information

Learning More About You

Confidentiality and Information Release

Photo/Social Media Release

Acknowledgment of Risk & Release of Liability

Covid-19 Acknowledgement of Risk

Hope Haven Concussion Protocol & Code of Conduct