Camp BSA Medical Form

PARTICIPANT’S APPLICATION & HEALTH HISTORY

Form must be completed in its entirety.
Forms without signatures/dates will be returned

GENERAL INFORMATION

Participant’s Full Name:

DOB:   Age:   Height:   Weight: lbs   Gender: M F

Address:

City:   State:   Zip:

Home Phone:

Cell Phone:

Work Phone:

E-mail address:

Employer/ School:

Address (if different from above):

Home Phone:   Work Phone:

Cell Phone:   Email Address:

Referral Source/ How did you hear about the program:

Special Need Y N Comments:

Parent/ Legal Guardian/Caregiver:

Relationship to Rider: Parent Guardian Caregiver

MEDICAL INFORMATION

Allergies:

Seizures: Yes No If yes, date of last seizure:

In Case of Emergency:

Contact Name: Relationship: Phone:

Contact Name: Relationship: Phone:

Medical Release:

In the event emergency medical aid/treatment is required due to illness or injury while present on the property of Whispering Manes, I authorize I do not authorize Whispering Manes Therapeutic Riding Center to secure transportation and medical treatment including x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital service rendered under the general or specific instructions of any physician or hospital. The undersigned hereby agrees to pay all fees and expenses of doctors, hospitals, ambulances and other medical expenses reasonably and necessarily incurred.

I understand that the information provided above is accurate to the best of my knowledge. I know of no reason why I should not participate in this center’s program. I acknowledge I have received Whispering Manes Therapeutic Riding Center's privacy policy.

I HAVE READ AND MADE A SELECTION FOR EMERGENCY MEDICAL AS INDICATED ABOVE:

PRIVACY STATEMENT

We are required by law to maintain the privacy of, and provide individuals with, this notice of legal duties and privacy practices with respect to your protected health information. If you have any objections to this form, please ask to speak with the Executive Director, in person or by phone.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out the formulation of a riding program and /or participation at Whispering Manes Therapeutic Riding Center (WMTRC), and/or for payment and for other purposes that are permitted or required by law.

Uses and Disclosures of Protected Health Information

Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your participation at Whispering Manes and any related services.

Payment. Your protected health information may be used, as needed, to obtain payment for your services.

Other Permitted and Required Uses and Disclosures. Will be made only with your consent, authorization or opportunity to object, unless required by law.

Your Rights. Following is a statement of your rights with respect to your protected health information.

Complaints. You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.

Waiver and Release of Liability for Participants

For good and valuable consideration, including the permission to participate and/or assist and/or volunteer in any and all equestrian assisted or other related activities with Whispering Manes Therapeutic Riding Center (WMTRC), located at 6105 SW 125th Avenue, Miami, FL, 33183, I agree and consent to the following:

WARNING

CAUTION: HORSEBACK RIDING CAN BE DANGEROUS. RIDE AT YOUR OWN RISK.

Under Florida Law, an equine activity sponsor or equine professional is not liable for any injury to, or the death of, a participant in equine activities resulting from the inherent risks of equine activities. FLORIDA STATE STATUTE 773.04

If the below Participant/Guest is a minor A LEGAL GUARDIAN and Participant MUST Sign Below.

NOTE: No minor/legal ward will be allowed on said property unless accompanied by an adult.

Having read the preceding, I acknowledge my understanding of those risks set forth herein and knowingly agree to accept full responsibility for my exposure to such risks.

I acknowledge a full and complete understanding of the limitations of liabilities and waiver of certain rights that I may have and granting of releases contained herein and knowingly consent thereto.

Print Participant Name:

Date of Birth of Participant:

Legal Guardian Signature:

Print Legal Guardian Name: