SOUTHERN STARRS
Therapeutic Horseback Riding and Animal Assisted Activities
INFORMATION FOR OUR STUDENTS, PARENTS AND GUARDIANS
Southern STARRS, its board members, and volunteers, strive to provide an enjoyable and SAFE riding experience for our students. We ask that you review the following information and facility rules in order to help us achieve this goal.
About Our Program (visit our website www.southernstarrs.org for more information)
Hippotherapy, a Greek term, literally translates as “treatment with the help of a horse.” Because a horse has a natural, rhythmic progressive gait, a swinging motion, which then transfers from horse to rider, horse-back riding provides a combination of sensory and neurological input that can be used to treat a broad range of disabilities. Hippotherapy is the basis for therapeutic riding in which students learn balance and coordination through activities that support the whole body. Additionally, Southern STARRS incorporates a learning curriculum as part of the class activities. We round out the class time with games and equestrian activities for a holistic type of student experience.
The horses used in our program are screened for their soundness and temperament and receive additional training to prepare them as therapy animals. Volunteers are required to complete training before working with our students. Parents or family members who bring students are encouraged to observe riding sessions in the designated parent waiting area. Siblings are welcome at our program, but must be supervised by a parent or guardian and remain in the designated waiting area. Southern STARRS requires that a parent/guardian remain on the premises at all times while their child rides.
Tuition for each session is based on the number of weeks in the session but breaks down to $15 for each class period. Classes last approximately 45 minutes but STARRS reserves the decision to reduce class time in inclement weather or if outdoor conditions are unfavorable (such as high heat and humidity). Although classes are held in an indoor area, if weather is prohibitive, we will notify you in the event that classes must be canceled. Tuition will be adjusted for canceled classes. If you need assistance with tuition costs, please let us now at time of application.
Students are required to wear an ASTME certified riding helmet at all times during riding classes. Students should be dressed in long pants, hard shoes or boots with an approx. 1-inch heel, and a comfortable top in keeping with weather conditions. Parents should supervise their children at all times when not riding. We will provide you with a schedule for your child's sessions. STARRS has a limited number of helmets available to use temporarily, however, we regret that due to insurance liability, and most importantly, OUR STUDENTS' SAFETY, students without a helmet will not be allowed to ride. Helmets may be purchased at any Tractor Supply Store, or at a local tack store of your choice, or can be ordered on the internet.
Southern STARRS is a 501(c)(3) non-profit organization. If you would like to help participate in our fund-raising programs, please let us know. We hold several events thoughout the year, and can always use extra help. Donations are always welcome from individuals, organizations, or corporate programs. Funds are used for operation, horse care, equipment purchase, insurance coverage, membership dues, volunteer training, printed materials and other direct program expenses. (The use of the facility, boarding of program horses, use of their own horses, and their TIME in directing the program are all donated by the co-founders of the program.) If you would like to become a volunteer, see a staff member regarding how this can apply toward a tuition discount.
PLEASE CALL, TEXT, OR EMAIL IF YOU HAVE QUESTIONS OR NEED ADDITIONAL INFORMATION.
THANK YOU FOR YOUR COOPERATION. WE LOOK FORWARD TO SERVING OUR STUDENTS!
SOUTHERN STARRS
Therapeutic Horseback Riding and Animal Assisted Activities
4050 CAIRO BEND RD LEBANON, TN 37087
Phone: (615) 453-2592 Cell (615) 428-3347 Email:
DIRECTIONS FOR FILLING OUT STUDENT REGISTRATION FORMS
1. Rider's Registration and Release Form:
a) Fill out the Registration portion, where applicable, as completely as possible, including emergency contacts.
b) Southern STARRS special events are occasionally covered by members of the media. Also, Southern STARRS maintains its own agency album of activities and events to be viewed upon request by funding organizations such as United Way. Student information is not released to the public, however, we respect our students' privacy, therefore, if you do not want your/your child's picture included in the above mentioned capacities, signing the photo release is optional.
2. Rider's Authorization for Emergency Medical Treatment Form:
a) Choose Consent or Non-Consent Plan. If you choose “Consent” please fill in information. (Forms must be signed by guardian if student is under 18 years of age.)
b) Fill out name, address, phone etc. portion and attach copy of insurance card if available
3. Participant's Consent for Release of Information:
a) Fill in participant's name, Date of Birth, and sign at Signature line. Please do not date or fill in any other information. This form will be used by Southern STARRS to annually update medical information with the student's physician, and such information will be held in strict confidentiality.
4. Rider's Medical History and Physician's Statement:
a) Please fill in Student's name, Date of Birth, Address, and name of parent/guardian. The remainder of this form must be filled in by the student's physician.
b) If the physician has any questions regarding this form, please have his/her office call Southern STARRS at 453-2592.
c) If Southern STARRS should be aware of any special precautions or concerns in the course of a therapeutic horse-back riding class for this student (i.e. seizure onset), the physician should indicate under Precautions.
After these forms have been completed, please return them to the Southern STARRS office, after which you will be contacted by a member of our staff to confirm a class schedule.
THANK-YOU
SOUTHERN STARRS, INC.
Rider’s Registration and Release Form
Student:______Date of Birth______
Street:______City:______State:______Zip:______
Please list contact numbers and circle your first preference.
Home/Cell______
Work ______Day or Evening: ______
Email:______
Parents or Guardian Name: ______
Address/Phone (if different than above):______
School or Institution presently attending (if applicable):______
In case of emergency contact:______Phone:______
contact:______Phone:______
Liability Release:
______(Student’s Name) would like to participate in the SOUTHERN STARRS program. I acknowledge the risks and potential for risks of horseback riding. However, I feel that the possible benefits to myself/my son/my daughter/my ward are greater than the risk assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against SOUTHERN STARRS, INC., its Board of Directors, Instructors, Therapists, Aides, Volunteers and/or Employees for any and all injuries and/or losses I/my son/my daughter/my ward may sustain while participating at SOUTHERN STARRS.
Date:______Signature:______
Student, Parent or Guardian
Photo Release (Optional)
I hereby consent to and authorize the use and reproduction by SOUTHERN STARRS, INC. of any and all photographs and any other audiovisual materials taken of me/my son/my daughter/my ward for promotional printed material, educational activities or for any other use for the benefit of the program.
Date:______Signature:______
Student, Parent or Guardian
Rider’s Authorization for Emergency Medical Treatment Form
□ Non-Consent Plan (parents of students under 18 or who cannot independently make life decisions are required to remain present during class so are not required to give consent for medical treatment. In the event of an emergency, staff will follow parent instruction.)
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency. In the event emergency treatment/aid is required, I will make healthcare decisions for myself/my child or person for whom I am the guardian.
Date:______Non-Consent Signature:______
(Student (over 18), Parent or Guardian) Print Name: ______Phone:______
Address:______
□ Consent Plan
In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize Southern STARRS, Inc. to:
1. Secure and retain medical treatment and transportation if needed
2. Release student records upon request to the authorized individual or agency involved in the medical emergency treatment.
This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “life saving” by the emergency responders/physician. This provision will only be invoked if the person below is unable to be reached.
Date:______Consent Signature:______
Print Name:______Phone:______
Address:______
Student’s Name:______Phone:______
Address:______
In the event I cannot be reached, contact:______Phone:______
contact:______Phone:______
Physician’s Name:______
Preferred Medical Facility:______
Health Insurance Co.:______Policy#:______
SOUTHERN STARRS, INC.
Rider’s Medical History and Physician’s Statement
Annual updates may be requested
Name:______Date of Birth:______
Address:______
Name of Parent/Guardian:______
Diagnosis:______Date of Onset:______
**For Persons with Down Syndrome:
ÿ Negative Cervical X-ray for Atlantoaxial Instability. X-ray date______
Negative for clinical symptoms of Atlantoaxial Instability.
Tetnus Shot: Yes No Date______Height______Weight______
Seizure Type______Controlled______Date of last seizure______
Medications:______
Please indicate if patient has a problem and/or surgeries in any of the following areas by checking yes or no. If yes, please comment.
Areas / Yes / No /Comments
Auditory
Visual
SpeechCardiac
Circulatory
Pulmonary
Neurological
Muscular
Orthopedic
Allergies
Learning Disability
Mental Impairment
Psychological Impairment
Other
Mobility: Independent Ambulation: Yes No Crutches: Yes No
Braces: Yes No Wheelchair: Yes No
Please indicate any special precautions: ______
Information for Physician
The following conditions, if present, may represent precautions or contraindications to therapeutic horseback riding. Therefore when completing this form, please note whether these conditions are present, and to what degree.
Orthopedic Medical/Surgical
Spinal Fusion Allergies
Spinal Instabilities/Abnormalities Cancer
Atlantoaxial Instabilities Poor Endurance
Scoliosis Recent Surgery
Kyphosis Diabetes
Lordosis Peripheral Vascular Disease
Hip Subluxation and Dislocation Varicose Veins
Osteoporosis Hemophilia
Pathologic Fractures Hypertension
Coxas Arthrosis Serious Heart Condition
Heterotopic Ossification Stroke (Cerebrovascular Accident)
Osteogenesis Imperfecta
Cranial Deficits
Spinal Orthoses
Internal Spinal Stabilization Devices
Neurologic Secondary Concerns
Hydrocephalus/shunt Behavior problems
Spina Bifida Age under two years
Tethered Cord Age two – four years
Chiari II Malformation Acute exacerbation of chronic disorder
Hydromyelia Indwelling catheter
Paralysis due to Spinal Cord injury
Seizure Disorders
SOUTHERN STARRS, INC.
Rider’s Consent for Release of Information
I hereby authorize: ______
(Person or Facility)
to release information from the records of: ______
(Student’s Name)
The information is to be released to: SOUTHERN STARRS, INC. for the purpose of developing a therapeutic riding curriculum for the above named student. The information requested is marked below:
______Medical History
______Physical Therapy evaluation, assessment and program plan
______Occupational Therapy evaluation, assessment and program plan
______Speech Therapy Evaluation, assessment and program plan
______Classroom Individual Education Plan (I.E.P.)
______Other: ______
Date:______
Signature:______
(Student (if over 18), Parent, or Guardian)
Please send the indicated material to: SOUTHERN STARRS, INC.
4050 CAIRO BEND RD.
LEBANON, TN 37087
SOUTHERN STARRS
Therapeutic Horseback Riding and Animal Assisted Activities
FACILITY RULES
1. Please park your vehicle behind the stables or to the side of the driveway in order to keep the driveway open for those arriving and leaving.
2. No alcoholic beverages or illegal substances are allowed on premises.
3. NO SMOKING around barn. You are welcome to sit in your car.
4. Do not climb, hang or sit on fence panels or mounting ramp.
5. If a gate is open, leave it open, if it's closed, please leave it closed.
6. PLEASE - no unruly behavior or yelling.
7. Do not allow children around horses without supervision.
8. If you bring horse treats, please ask a volunteer to assist with feeding the horse.
9. If you are not a student, please stay outside of the riding area.
10. Picture taking must be cleared with TR Program Director first.
11. Please see Riding Instructor, Executive Director, or other staff member
if you have any questions or concerns.
12. Please call and notify us if you will not be attending a riding session. OUR VOLUNTEER'S GIVE THEIR TIME. IF YOU DON'T ATTEND AND DON'T LET US KNOW, YOU HAVE DISRESPECTED THEIR CONTRIBUTION!
These rules are put in place for our students’ safety, our horses’ wellbeing and in consideration of others. Observation of these rules is mandatory! Your understanding is appreciated.
I have read and understand these rules and will comply with the criteria set forth by the program: (please sign and return with forms)
______
(Student/parent/guardian signature)
“Where People Shine”
SOUTHERN STARRS
Therapeutic Horseback Riding and Animal Assisted Activities
FACILITY RULES
1. Please park your vehicle behind the stables or to the side of the driveway in order to keep the driveway open for those arriving and leaving.
2. No alcoholic beverages or illegal substances are allowed on premises.
3. NO SMOKING around barn. You are welcome to sit in your car.
4. Do not climb, hang or sit on fence panels or mounting ramp.
5. If a gate is open, leave it open, if it's closed, please leave it closed.
6. PLEASE - no unruly behavior or yelling.
7. Do not allow children around horses without supervision.
8. If you bring horse treats, please ask a volunteer to assist with feeding the horse.
9. If you are not a student, please stay outside of the riding area.
10. Picture taking must be cleared with the TR Program Director first.
11. Please see Riding Instructor, Executive Director, or other staff member
if you have any questions or concerns.
12. Please call and notify us if you will not be attending a riding session. OUR VOLUNTEER'S GIVE THEIR TIME. IF YOU DON'T ATTEND AND DON'T LET US KNOW, YOU HAVE DISRESPECTED THEIR CONTRIBUTION!
These rules are put in place for our students’ safety, our horses’ wellbeing and in consideration of others. Observation of these rules is mandatory! Your understanding is appreciated.
“Where People Shine”
(Student/Parents’ copy – please retain for reference)
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