HHH Participant Application

 

Participant Application Form

Dear Parent / Guardian:

Thank you for your interest in Horses Healing Hearts. HHH is a 501c3 organization that is dedicated to helping children of alcoholics and addicts build self-esteem and confidence by working with horses. In addition to our curriculum-based support groups we use the horses as a vehicle to teach children empathy, trust, boundaries, and responsibility. Our goal is to end the generational cycle of addiction. Please note HHH is not therapy.

Please complete the information below. Upon review of the attached information, we will contact you regarding the next step in your child becoming a participant in Horses Healing Hearts.

 

TUITION INFORMATION
HHH works to keep our program fees as low as possible.

Our session expense for each child is $80.00; however, a portion of this amount is subsidized through support of our generous  donors. Consequently, we are able to offer a sliding fee scale so every child has the opportunity to take advantage of our services. In order to maintain minimal administrative expenses, each parent/guardian is required to pay their child’s fees by registering for the automated monthly payment system through pay pal.

Financial assistance may be available to those who qualify. To apply for financial assistance, please provide either 2 pay stubs or a tax return. If unemployed, please provide proof of state or county assistance.

No child will ever be turned away due to financial reasons. 

This agreement is designed to help build a positive working relationship between
you, your child, and HHH. It also informs you of you and your child’s rights and
responsibilities within our organization. If you have questions or concerns, please
feel free to discuss them with HHH.

RSVP (SignUp.com)
You will receive an email regarding session times and you will need to respond to the email to effectively RSVP for the session. RSVP is required so that we can confirm that there is enough, volunteers, trainers and horses. If you do not RSVP, there is a chance that your child will not be able to ride for that day. If you need to cancel the child’s attendance for a session for any reason, please notify us via phone at 877-467-7310 or info@hhhusa.org, at least 24 hours in advance.

GROUP RULES

  • One person talks at a time
  • Respect each other
  • You can pass
  • Put ups only
  • What we say here stays here

CONFIDENTIALITY

Although we are a prevention program and not a therapy service, we are
mandated by the state of Florida to report any child’s sharing of the
following:

  • Threats of suicide
  • Threats of self-harming
  • Incident of harming another person

Due to fact the child is our client, we are committed to maintaining
confidentiality with any information they share, with the exception of the
three points above.

Please allow 2 to 4 days for our administrative offices to review your application.

If your child is an eligible candidate for our programs, an office representative will call or email you within five days to schedule an in person meeting at a later date to review the application in more detail.

For any further questions please contact info@hhhusa.org
or call 1-877 HORSE 10.

*There are no refunds for missed sessions

INTAKE FORM

Please provide the following information for our records. The information you
provide here is held to the highest standards of confidentiality.

The undersigned participant and/or parent or legal guardian, acknowledges that there are inherent risks involved in riding and working around horses. Those risks include injury, personal property damage, and death, and the risks arise from using, riding, or being in close proximity to horses. The undersigned participant also acknowledges that both horse and rider can be injured in normal use or in competition and schooling. With full understanding of the risks stated in the above paragraph, the undersigned participant does hereby release and hold harmless the following listed entities from any and all claims, including claims of either active or passive negligence, related to or arising from the undersigned participant’s interactions with the following listed entities: Horses Healing Hearts, Inc. and it’s Board of Directors, Officers, Committees, Assignees, volunteers, stated or implied agents (either individually or in their corporate capacity) heirs, successors, assigns, executors, and legal representative. The undersigned participant and or parent or legal guardian, further agrees to indemnify the above-listed entities for all costs, losses, damages, and expenses, including court costs and reasonable attorneys’fees, suffered by any of the above-listed entities arising out of any and all claims, including claims of either active or passive negligence, brought in relation to the undersigned participant’s interactions with the above-listed entities. I DO EXPRESSLY CONSENT TO ASSUME THE RISK OF ANY CHANGE OF HARM, INJURY, DEATH, PERSONAL DAMAGE, REAL PROPERTY DAMGE, OR SUFFERING, ARISING FROM OR IN THE COURSE OF MY, OR SAID MINOR’S PRESENCE ON THE PREMISES OF ANY HHH SPONSOR BARN PROPERTY. The following statement is made in accordance with Florida Statute 773.04: Under Florida Law, an equine sponsor or equine professional is not liable for an injury to, or death of, a participant in equine activities resulting from the inherent risks of equine activities Additionally, Horses Healing Hearts’ employees, volunteers, contractors, and agents all fully comply with Florida Statute 39.201, which requires that any person who knows, or who has reasonable cause to suspect, that a child is intending to harm his/herself or others, is abused by an adult other than a parent, legal custodian, caregiver, or other person responsible for the child’s welfare, shall report such knowledge or suspicion to the Florida Department of Children and Families I have received, read and understand the Prevention Support Group Agreement and Notice of Privacy Rights. I authorize the release of the minimum amount necessary of my child’s personal health information to Horses Healing Hearts, Inc.