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Participant's Application and Health History form
 
Participant:
Age: Height:
Weight:
Date of Birth:
Male:
Female
 
Phone:
How did you hear about the Program?
 
Contact Numbers:
Alternative number:
Employer/School:
Address:
Phone:
Parent/Legal Guardian:
Address (if different from above):
Phone(if different from above):
Referral Source:
 
Health History Form
Please indicate current or past problems in the following areas:
 
Yes
No
Comments:
Vision
Hearing
Sensation
Communication
Heart
Breathing
Digestion
Elimination
Circulation
Emotional
Behavioral
Pain
Bone/Joint
Muscular
Thinking/Cognition
Allergies
What medications are you currently taking, including over-the-counter medications?
 
Describe your abilities/difficulties in the following areas (include assistance required or equipment needed)
SOCIAL
(i.e. Work/School including grade completed, leisure interests, relationships/family structure, support systems,
companion animals, fears/concerns, etc)
GOALS
FUNCTION
(i.e. Why are you applying for participation?
What would you like to accomplish?)
(i.e. Mobility skills such as transfers, walking,
wheelchair use, driving/bus riding)
Photo Release
I do I do not consent to and authorize the use and reproduction by Jacobs' Ladder Therapeutic Riding Center of any
and all photographs and any other audio/visual materials taken of me for promotional material, educational activities,
exhibitions or for any other use for the benefit of the program.
By clicking Submit, I (the applicant) , agree to all terms and
policies as stated by Jacobs' Ladder Therapeutic Riding Center, Inc.
 You may also print the form and mail it to Jacobs' Ladder 5866 Bradford Rd. N. ,Hahira, GA 31632
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