Hooves to Heal 20604 Collins Rd.
Marengo, Illinois, 60152 Patty Mozal ~
Volunteer/Staff Health History and Medical Information
Volunteer/Staff Name:___________________________________Date of Birth:_____________
Address:______________________________________________________________________
Phone:________________________Alternate Phone:__________________________________
Physician’s Name:______________________________________Phone:___________________
Preferred Medical Facility:___________________________________________US Citizen Y N
Health Insurance Provider:________________________________Policy #_________________
A therapeutic horse riding program can be very physically demanding. Handling of tack and other equipment, grooming, and assisting in the mounting/dismounting of participants may involve heavy lifting and reliance upon physical strength. In addition, volunteers may be required to walk, jog alongside the horses, or stand for extended periods of time. Our goal is to match our volunteers and staff with the appropriate participant, horses and tasks to maximize the safety and benefits of our therapeutic riding program for all. Please provide us with the following health information:
Any restrictions (Please check all that apply):
Lifting ∼ Running ∼ Walking ∼ Standing ∼ Other ∼
Please explain restrictions:_______________________________________________________
_____________________________________________________________________________
Please explain your current health status, particularly any information that may impact the physical and emotional demands involved in a therapeutic horse back riding program. Please be sure to address fitness, cardiac, respiratory, bone or joint function, or any other information regarding your current health history of which you believe we should be advises:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Date of last Tuberculosis test: ____________ Results? + –
Allergies:________________________________Medications:___________________________
IF ANY INFORMATION REGARDING YOUR HEALTH CHANGES, PLEASE BE
SURE TO UPDATE OUR RECORDS
Signature:________________________________________________Date:________________