Rider Renewal Form – Giant Steps Therapeutic Equestrian Center

Contact Information

Participant First Name*

Participant Last Name*

Birthdate*

Your birthdate is required as it will allow us to identify your participant information in our database.

Email Address*

Enter email Confirm email

Mobile Phone Number

Home Phone Number

Address

Street Address City State ZIP Code

Updated Confidentiality Policy

Our confidentiality policy has changed. Please review and sign your consent to the new policy.

I understand that all information (written and verbal) about participants at this PATH center is confidential. Client files may be accessed by Giant Steps instructors and staff but will not be shared with anyone without the expressed written consent of the participant and their parent/guardian in the case of a minor. Limitations to this confidentiality policy are as follows:

If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
Information shared by a minor does not need to be kept confidential from their caregiver.
If a Giant Steps instructor or staff member has a reasonable suspicion that the client is the perpetrator, observer of, or victim of physical, emotional, or sexual abuse or neglect of children under the age of 18, persons with a disability, or an elderly person.
If a court of law issues a legitimate subpoena for the information stated in the subpoena.

Please type your full name*

Signature*

Commitment to Equality

In our commitment to equity and inclusion, we track data on our clients, volunteers, and staff. This data is merely for us to evaluate our progress on our equity and inclusion work.It does not affect your application in any way, and is completely voluntary to complete.

Gender

Preferred Pronouns

Preferred Pronouns Other

Please tell us your preferred pronoun

I identify ethnically as

Health Update

Please list any changes in medical condition, medication, physical function, and/or psychosocial function*

Consent to Exchange Confidential Information

I authorize the exchange of information described below between Giant Steps Therapeutic Equestrian Center and the following agencies and/or individuals.

Please check ALL that apply

Primary Care Physician's Name, Email, Phone

Specialist Physician's Name, Email, Phone

Parent / Guardian's Name, Email, Phone

Physical Therapist's Name, Email, Phone

Occupational Therapist's Name, Email, Phone

Speech Therapist's Name, Email, Phone

Psychotherapist's Name, Email, Phone

Teacher/Educator's Name, Email, Phone

Other Name, Email, Phone

This authorization applies to the following information (check each line that applies)

Expiration: This authorization is ongoing unless cancelled in writing by the client.

Restrictions: Providers who receive this information may not release it to someone else unless another authorization form is signed.

Your Rights: You may refuse to sign this form. You may cancel it at any time by informing Giant Steps Therapeutic Equestrian Center in writing. If you cancel your permission to allow the release of information about you / your child, it will go into effect immediately (unless someone already released information). You have the right to receive a copy of this Authorization