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2019 SU Hippotherapy Application |
- Age 10 - 16
- Self reported symptoms of anxiety or depression
- No previous participation in Hippotherapy or Therapeutic Riding
- Independent ambulation and communication
- Must be available for all the dates listed below
Sunday March 24th
Sunday March 31st
Sunday April 14th.
38416 Morrisonville Road
Lovettsville, VA 20180
 INFO: | Please note that this form contains limited capacity items which are sold out. They are displayed grayed out and/or are not selectable. |
Autumn O'Hara, OTD, MS, OTR/L, HPCS
703-298-5319
rideonranch@gmail.com
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Registrant |  |
PARTICIPANT INFORMATION
EMERGENCY CONTACT INFORMATION
Ride-On Ranch Equine Assisted Therapies, LLC (Ride-On Ranch)is considered an out-of-network provider for all health insurance companies. All services provided byRide-On Ranch are fee for service. If you have out-of-network coverage, you may choose to submit claims to your health insurance company. Ride-On Ranch will not submit claims on the patient’s behalf, nor negotiate with any insurance companies for reimbursement.
It is your responsibility to find out if your healthinsurance company will or will not reimburse for the services received fromRide-On Ranch. If requested, Ride-On Ranch can provide you with all treatmentnotes for submission to your health insurance company. All treatment notes fromRide-On Ranch clearly reflect the nature and scope of services provided,including but not limited to the use of equine movement as part of an integratedtreatment strategy.
By clicking "I agree” you understand and acknowledge the exclusion policies that some insurance companies may have. You agree to take full responsibility for all claim submissions made to your insurance company, including but not limited to notifying the insurance company of the specific treatment that the patient is receiving at Ride-On Ranch.
Occupational Therapy
Speech
Hearing concerns
Diet/feeding concerns
1. Waiver and Release: I am fully aware of and appreciate the risks, including the risk of catastrophic injury, paralysis, and even death, as well as other damages and losses, associated with participation in a equine-related events and related activities. I further agree
on behalf of myself, my heirs and personal representatives, that Autumn O'Hara along with Ride-On Ranch or Belisle Corp LLC, volunteers, employees, agents, sponsors, officers, and directors of these organizations, shall not be liable for any injury, loss of life or other loss or damage occurring as a result of my participation in the event.
2. Medical Attention: I hereby give my consent to Ride-On Ranch to provide, through a medical staff of its choice, customary medical attention, transportation and emergency medical services as warranted in the course of my participation in Ride-On Ranch sponsored or sanctioned events.
3. Readiness to Participate: I will only participate in those activities in which I believe I am physically and psychologically prepared to participate.
As legal guardian of this participant, I hereby verify that I have read and fully understand each of the conditions under Participant Waiver and Release section for permitting my dependent to participate in any Ride-On Ranch sponsored events and activities and I accept each of the conditions, especially the waiver and release set forth in paragraph one.
Insurance Information
All participants are required to be covered with insurance for accidental injury. In most instances, family health insurance is adequate. Please indicate your family health insurance plan above.
Medical Treatment Authorization
I/We being the legal guardians of the applicant authorize Ride-On Ranch and its agent’s permission to request medical treatment as necessary to ensure the well being of our dependent.
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