Adult Rider Package
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Pacific Riding for Developing Abilities 1088 – 208th Street, Langley BC, V2Z 1T4 • Phone: 604-530-8717 • Fax: 604-530-8617 www.prda.ca • Business # 11907 5620 RR0001
Dear Potential Rider/Parent/Guardian:
Thank-you for your interest in our programs here at Pacific Riding for Developing Abilities. Enclosed you will find:
1. Letter for the Applicant’s Physician
2. Physician’s Referral Form
3. List of Precautions and Contraindications
4. Parent/Guardian Release and Waiver of Liability
5. Photo Release Form
6. Authorization for Emergency Medical Treatment Form
Please give items 1, 2, and 3 to the applicant’s physician and have the physician complete the Physician’s Referral Form. As well, the applicant or parent/guardian of the applicant must complete items 4, 5, and 6. All original forms should be returned to us either by mail or in person.
Once these forms are received, the applicant will be placed on our waiting list. When a suitable spot becomes available, they will be contacted to arrange an assessment with the Instruction Coordinator. This is so we can have a face-to-face meeting with the potential participant and assess their suitability for the program, horse requirement and any special equipment and volunteers that may be required.
Once again, thank you for your inquiry into our programs. Please feel free to stop by anytime and have a look around and meet our horses and staff. If you have any questions, please feel free to call us at 604-530-8717.
Sincerely,
Pacific Riding for Developing Abilities
MISSION STATEMENT
Through equestrian activities and with the involvement of the community, we enhance the quality of life for individuals with a wide range of challenges.
Pacific Riding for Developing Abilities 1088 – 208th Street, Langley BC, V2Z 1T4 • Phone: 604-530-8717 • Fax: 604-530-8617 www.prda.ca • Business # 11907 5620 RR0001
Dear Doctor:
Thank you for completing the Physician’s Referral Form for your patient to participate in one of our programs at Pacific Riding for Developing Abilities. Your comments will greatly help our Instructors provide a better quality program for the applicant. Where possible, be specific with your comments.
Please take some time to review the list of Contraindications and Precautions, and consider the ones that may be applicable to your patient. If you have any questions or concerns, please contact the PRDA office at 604-530-8717. Further, please review the list of conditions that require a cervical spine and/or flexion/extension x-ray. If an x-ray is indicated, please attach a copy of the results to this Referral.
When a suitable spot for your patient becomes available, he/she will be contacted to arrange an assessment with the Instruction Coordinator at PRDA. This is so we can have a face-to-face meeting with the potential participant and assess their suitability for the program, horse requirements, and any special equipment and volunteers that may be required.
Riding is considered a high-risk sport, therefore the highest safety standards are always maintained at PRDA. Our Coaches are all certified, with knowledge of teaching in a therapeutic riding setting, and are familiar with people with both physical and/or cognitive disabilities. Our Instructors are working towards Coaching certification, and are mentored and supervised by Coaching staff.
Thank you again for completing the Physician’s Referral Form. If you have any questions or concerns regarding your patient’s participation in our program, or have any other questions about PRDA or therapeutic riding in general, please do not hesitate to call our office.
Sincerely,
Pacific Riding for Developing Abilities
MISSION STATEMENT
Through equestrian activities and with the involvement of the community, we enhance the quality of life for individuals with a wide range of challenges.
Pacific Riding for Developing Abilities
1088 – 208th Street, Langley BC, V2Z 1T4 • Phone: 604-530-8717 • Fax: 604-530-8617 www.prda.ca • Business # 11907 5620 RR0001
PHYSICIAN’S REFERRAL
NAME OF RIDER | PHONE | ||||
ADDRESS | CITY/POSTAL CODE | ||||
GENDER | DATE OF BIRTH | WEIGHT | HEIGHT | ||
DIAGNOSIS | DATE OF ONSET | EMAIL ADDRESS |
RIDER’S PATENT/GUARDIAN/CONTACT NAME | PHONE |
PLEASE BE SPECIFIC WHEN COMMENTING ON IMPAIRMENTS
AUDITORY IMPAIRMENTS | NO | YES | |
SPEECH IMPAIRMENTS | NO | YES | |
ORAL MOTOR FUNCTION | NORMAL | ABNORMAL | |
VISUAL IMPAIRMENTS | NO | YES | |
PSYCHOLOGICAL OR BEHAVIOURAL CONCERNS | NO | YES | |
CIRCULATORY IMPAIRMENTS | NO | YES | |
SENSATION | YES | NO (WHERE) | |
INCONTINENCE | BOWEL | NO | YES |
BLADDER | NO | YES | |
SPINAL/JOINT ABNORMALITIES | NO | YES | |
HIP SUBLUXATION OR DISLOCATION | NO | YES | |
COORDINATION IN UPPER EXTREMITIES | NORMAL | ABNORMAL | GROSSLY ABNORMAL |
COORDINATION IN LOWER EXTREMITIES | NORMAL | ABNORMAL | GROSSLY ABNORMAL |
MISSION STATEMENT
Through equestrian activities and with the involvement of the community, we enhance the quality of life for individuals with a wide range of challenges.
MUSCLE TONE | ARMS | NORMAL | HIGH TONE | LOW TONE | |
LEGS | NORMAL | HIGH TONE | LOW TONE | ||
TRUNK AND NECK | NORMAL | HIGH TONE | LOW TONE | ||
BALANCE | STATIC SITTING | GOOD | FAIR | POOR | |
DYNAMIC SITTING | GOOD | FAIR | POOR | ||
STATIC STANDING | GOOD | FAIR | POOR | ||
DYNAMIC STANDING | GOOD | FAIR | POOR | ||
SEIZURES (SEE LIST IF CONTRAINDICATIONS) | NONE | YES (LIST TYPE) | |||
PRE-SEIZURE INDICATORS | DATE OF LAST SEIZURE | ||||
MEDICATIONS | NONE | YES (PLEASE SPECIFY) | |||
MEDICATION SIDE EFFECTS | NONE | YES (PLEASE SPECIFY) | |||
RELEVANT SURGERIES AND DATE | |||||
LAST TETANUS VACCINATION DATE | |||||
ALLERGIES | |||||
ASSISTIVE DEVICES OR BRACES | NONE | YES (PLEASE STATE) | |||
DOWNS SYNDROME & RHEUMATOID CERVICAL SPINE X-RAYS (SUB OCCIPITAL & ATLANTO/AXIAL JOINTS)* (SEE LIST OF CONTRAINDICATIONS) | YEAR | ||||
FLEXION/EXTENSION X-RAYS REQUIRES* (SEE LIST OF CONTRAINDICATIONS) | YEAR | ||||
*WHEN APPLICABLE, PLEASE INCLUDE A COPY OF CERVICAL SPINE OR FLEXION/EXTENSION X-RAY REPORT | |||||
IN MY OPINION, THIS PATIENT CAN RECEIVE THERAPEUTIC HORSEBACK RIDING LESSONS UNDER PROPER INSTRUCTION. I UNDERSTAND THAT THIS PATIENT MAY RECEIVE ASSESSMENT/TREATMENT BY A VOLUNTEER PHYSIOTHERAPIST OR OCCUPATIONAL THERAPIST, IN CONJUNCTION WITH THIS RIDING PROGRAM REGARDING HIS/HER PHYSICAL AND/OR BEHAVIOURAL ABILITIES/LIMITATIONS IN PERFORMING WITH THIS PROGRAM. | |||||
COMMENTS |
DR’S STAMP – NAME/ADDRESS/PHONE (REQUIRED) | SIGNATURE |
DATE |
Pacific Riding for Developing Abilities 1088 – 208th Street, Langley BC, V2Z 1T4 • Phone: 604-530-8717 • Fax: 604-530-8617 www.prda.ca • Business # 11907 5620 RR0001
GUIDELINES FOR PHYSICIANS/THERAPISTS
CONTRAINDICATIONS AND PRECAUTIONS FOR THERAPEUTIC RIDING
The following conditions may represent precautions or contraindications to therapeutic horseback riding if present in potential students. Therefore, when completing the Physician’s Referral, please note whether these conditions are present and to what degree.
ABSOLUTE CONTRAINDICATIONS
ORTHOPEDIC:
∙ Acute arthritis
∙ Acute herniated or prolapsed disc
∙ Atlanto-axial instabilities
∙ Coxa athrosis (degeneration of hip joint)
∙ Structural cranial deficits
∙ Osteogenesis imperfecta
∙ Pathological fractures
∙ Spondylothesis
∙ Structural scoliosis >30 degrees, excessive kyphosis or lordosis or hemivertebra ∙ Spinal stenosis
NEUROLOGICAL:
∙ CVA 2nd to unclipped aneurysm or angioma
∙ Paralysis due to spinal cord injury above T6 (adult)
∙ Spina bifida associations – Chiari II Malformation, Hydromyelia, Tethered Cord ∙ Uncontrolled (grand mal) seizures within last 6 months
MEDICAL/PSYCHOLOGICAL:
∙ Obesity >170 lbs
∙ Andcoaguiams
OTHER:
∙ Age under 2 years old
∙ Any condition that the instructor, therapist, physician or program does not feel comfortable treating
RELATIVE CONTRAINDICATIONS AND PRECAUTIONS
ORTHOPEDIC:
∙ Arthrogryposis
∙ Heterotrophic ossification
∙ Hip subluxation, dislocation or dysphasia
∙ Osteoporosis
∙ Spinal fusion/fixation, Harrington Rods (within 2 years of surgery)
∙ Spinal instabilities/abnormalities
∙ Spinal orthoses
MISSION STATEMENT
Through equestrian activities and with the involvement of the community, we enhance the quality of life for individuals with a wide range of challenges.
NEUROLOGIC:
∙ Neuromuscular disorders: Amyotrophic Lateral Scleroses, Fibromyalgia, Gullian Barre, exacerbation of Multiple Sclerosis, Post Polio Syndrome
∙ Hydrocephalic shunt
MEDICAL/PSYCHOSOCIAL:
∙ Abusive or disruptive behavior
∙ Cancer
∙ Hemophilia
∙ History of skin breakdown or skin grafts
∙ Abnormal fatigue
∙ Incontinence (must wear protection)
∙ Peripheral vascular disease
∙ Sensory deficits
∙ Serious heart condition or hypertension
∙ Significant allergies
∙ Surgery within the last three months
∙ Uncontrolled diabetes
∙ Indwelling catheter
∙ Substance abuse
FLEXION/EXTENSION X-RAY REQUIRED FOR ATRAUMATIC FACTORS THAT MAY BE ASSOCIATED WITH AN UNSTABLE UPPER CERVICAL SPINE:
∙ Os odontoidum
∙ Down syndrome
∙ Athetoid cerebral palsy
∙ Rheumatoid arthritis of cervical vertebrae
∙ Congenital torticollis
∙ Sprengel deformity
∙ Ankylosing Sponylitis
∙ Congenital atlato-occipital instability
∙ Klippel-Fwil syndrome
∙ Chairi malformation with cfondylar hydroplasia
∙ Fusion of C2-C3
∙ Lateral mass degeneration change at C1-C2
∙ Systemic lupus
∙ Morquio disease
∙ Non-rheumatoid cranial settling
∙ Subluxation of upper cervical vertebrae due to tumors or infections
∙ Idiopathic laxity if the ligaments
∙ Grisel’s syndrome
∙ Lesch-Nyhan syndrome
∙ Marshall-Smith syndrome
∙ Diffuse idiopathic hyperostosis
∙ Congenital chondrodysplasia
Pacific Riding for Developing Abilities 1088 – 208th Street, Langley BC, V2Z 1T4 • Phone: 604-530-8717 • Fax: 604-530-8617 www.prda.ca • Business # 11907 5620 RR0001
RELEASE AND WAIVER OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT (Adult Rider)
Pacific Riding for Developing Abilities takes every precaution to ensure a safe and secure environment. However, despite taking all efforts to provide a safe environment we must warn those using the facility that there are inherent dangers associated with horse riding facilities.
(I), , hereby acknowledge and agree that in consideration of being permitted to participate as a rider for Pacific Riding for Developing Abilities we (I) release Pacific Riding for Developing Abilities, their employees, directors, agents, independent contractors, subcontractors, representatives, sponsors, volunteers, successors and assigns (referred to collectively as PRDA) from all liability, claims, causes of action of any kid whatsoever in respect of all personal/bodily injury, death or property loss which I might suffer resulting from any cause whatsoever including but not limited to: • The risks, dangers and hazards of being around and/or riding horses, • The risks, dangers and hazards associated with participating in a therapeutic riding program, • Risks, dangers and hazards associated with being around barn, arena and farm equipment • Any loss or injury caused by negligence, breach of contract or breach of statutory duty of care on the part of PRDA. |
I acknowledge that participation in riding activities for PRDA involves working with and around horses in barns, arenas, and outdoors and working with riders of various ages with physical and cognitive challenges. These activities can be dangerous and expose me to risk of injury and/or death and/or property damage and I freely and voluntarily assume all such risks. I hereby agree this Release and Waiver of Liability and Assumption of Risk extends to all acts or omissions including those constituting negligence by PRDA and is intended to be as broad and inclusive as is permitted by the laws of British Columbia and if any portion thereof is held to be invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. |
I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY AND ASSUMPTION OF RISK AND FULLY UNDERSTAND ITS TERMS AND UNDERSTAND THAT I HAVE GIVEN UP ESSENTIAL LEGAL RIGHTS BY SIGNING IT. I HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE AND INTENDED MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.
Rider’s Signature Witness’ Signature
Dated Print Witness Name Telephone Number
MISSION STATEMENT
Through equestrian activities and with the involvement of the community, we enhance the quality of life for individuals with a wide range of challenges.
Pacific Riding for Developing Abilities
1088 – 208th Street, Langley BC, V2Z 1T4 • Phone: 604-530-8717 • Fax: 604-530-8617 www.prda.ca • Business # 11907 5620 RR0001
PHOTO/INFORMATION RELEASE CONSENT FORM
(Adult Rider)
(I), , hereby give any person authorized by Pacific Riding for Developing Abilities (PRDA) permission to take still and moving photographs and video recordings accompanied by verbal or written identification of me, and I give consent to PRDA to use, reproduce, publish, or otherwise circulate such photographs and/or video recordings in promotion of PRDA. I permit the following Information about the rider to be published: Name: Age: Special Challenges: Date Signature |
MISSION STATEMENT
Through equestrian activities and with the involvement of the community, we enhance the quality of life for individuals with a wide range of challenges.
Pacific Riding for Developing Abilities 1088 – 208th Street, Langley BC, V2Z 1T4 • Phone: 604-530-8717 • Fax: 604-530-8617 www.prda.ca • Business # 11907 5620 RR0001
RIDER’S AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT FORM
In the event emergency medical aid/treatment is required due to illness or injury during the process or receiving services, or while being on the property of the agency, I authorize
(Operation Center’s Name) to:
1. Secure and retail 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: Phone: Address:
In the event I cannot be reached, contact: Phone: contact: Phone:
Physician’s Name:
Preferred Medical Facility:
Health Insurance Co.: Policy #:
Consent Plan
This authorization includes x-rays, surgery, hospitalization, medication and any treatment procedure deemed “life saving” by the physician. This provision will only be invoked if the person below is unable to be reached.
Date: Consent Signature:
Print Name: Phone: Address:
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 whole being on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedures to take place:
Date: Consent Signature:
Print Name: Phone: Address:
MISSION STATEMENT
Through equestrian activities and with the involvement of the community, we enhance the quality of life for individuals with a wide range of challenges.