Participant Information
*
First Name
Last Name
Date of brith
*
MM
DD
YYYY
Home Phone
(###)
###
####
Mobile Phone
*
(###)
###
####
Email
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent / Guardian Information
If the participant is under 18 years of age at this time, we require that their parent / guardian information.
First Name
Last Name
Parent/Guardian Phone Number
(###)
###
####
Emergency Contact Name (1st)
*
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
Gender
Select an answer only if you want to.
Male
Female
Nonbinary
Decline to state
Preferred Pronouns
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He/Him/His
She/Her/Hers
They/Them/Theirs
Other
Decline to state
I identify ethnically as
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American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Multi-ethnic
Other
Decline
Please list any changes in medical condition, medication, physical function, and/or psychosocial function
*
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
This authorization applies to the following information (check each line that applies)
Please type your full name
*
