Child 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 (Rider Under 19)

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. 

We (I), , hereby acknowledge and agree that in consideration of  (name of participant) 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.

We (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 our child/ward to risk of injury  and/or death and/or property damage and we (I) freely and voluntarily assume all such risks for our  child/ward. 

We (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.

WE (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. WE (I) HAVE SIGNED IT FREELY AND  VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE AND INTENDED OUR (MY) SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW. 

Parent/Guardian’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 

(Rider Under 19)

We (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 our child/ward,  

(name of rider), and we (I) give consent to PRDA to use,  

reproduce, publish, or otherwise circulate such photographs and/or video recordings in promotion of  PRDA. 

We (I) permit the following Information about the rider to be published: 

Name: 

Age: 

Special Challenges: 

Date Signature of Parent/Guardian

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. 

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