Participant Application

PARTICIPANT APPLICATION INFORMATION (required)

All information you provide on this form is kept strictly confidential. Please confirm you have read the PARTICIPANT APPLICATION INFORMATION at the end of this section.

Thank you for your interest in Champ’s Heart! Please read carefully through the information provided in this packet before completing the application forms.

Statement of Purpose: Champ’s Heart is an equine-based ministry offering children with limited abilities, veterans of war, and their families the opportunity to experience the healing nature of horses and experience a sense of independence in a welcoming environment. Champ’s Heart does not offer equine therapy, but rather an opportunity for children and their families to interact with and experience the benefits of encounters with horses.

Location: Champ’s Heart meets at 988 South 45th East, Idaho Falls, Idaho. No one is allowed on the property outside of scheduled Champ’s Heart sessions, or by invitation.

Who May Participate:
• Our participants are between the ages of two and twenty, but we do make exceptions. All exceptions must be approved by either the Program Manager or Larry Cudmore, CEO of Champ’s Heart.
• Participants must be able to maintain head and neck position without assistance.

All applicants are evaluated prior to interacting with horses to ensure that these encounters can be safely provided.

I certify I have read the PARTICIPANT APPLICATION INFORMATION:

Yes

RULES FOR PARTICIPANTS (required)

Please confirm you have read the RULES FOR PARTICIPANTS at the end of this section.

1. All required forms must be fully completed, signed, and submitted before any applicant will be considered for Champ’s Heart. This applies to all family members intending to participate.

2. If the participant is under eighteen, a parent or other designated adult caregiver must always remain in the Champ’s Heart area while the participant is on Champ’s Heart property.

3. Sessions are 50-minutes in length, starting at the top of the hour. If you are late, the session still concludes 50 minutes after your scheduled start time.

4. This is NOT a riding class, with formal riding lessons.

5. This is NOT a licensed horse therapy program.

6. Only volunteers and participants are allowed beyond designated Champ’s Heart visitor areas.

7. Participants and guests may not approach or touch horses anywhere on the premises without the permission of a Champ’s Heart designated volunteer.

8. If a Champ’s Heart staff member or designated volunteer deems that anyone on the premises is creating an unsafe environment for the students, horses, volunteers and/or staff, they will be asked to leave the property.

9. No running is allowed on the premises.

10. Items that may be distracting such as balloons, noise-making devices, or toys are not allowed.

11. Participants must be dressed appropriately for horse related activities or they will not be permitted to ride. This includes:
• Comfortable, closed-toe and closed-heel shoes and socks
• Long pants
• Weather appropriate attire (jacket, gloves, etc.)

12. All participants must wear an ASTM-SEI certified riding helmet to participate. Helmets will be provided by Champ’s Heart. If a student prefers their own helmet, it must be approved by the Program Manager and be less than five years old.

13. All participants under eighteen must wear safety belts while mounted. These are to be placed on the participant before they are seated on the horse.

14. Before taking photos or videos, please obtain permission from onsite supervisor. Do not use flash photography.

15. Please leave your furry animals at home. Personal pets are not allowed on Champ’s Heart premises. If a service animal is required, it must stay away from any riding areas. If service animals create a disturbance, the owners will be asked to remove them.

16. Champ’s Heart is a tobacco, drug, and alcohol-free environment. Smoking is strictly prohibited. Anyone showing signs of substance use will be asked to leave the premises immediately.

17. Champ’s Heart strives to provide a safe, supportive, and compassionate environment. Hostile or threatening behavior of any kind will not be tolerated. This includes, but is not limited to, physical or verbal abuse, gossip, insults, ridicule, harassment, or discrimination of any kind.

18. In the event of an incident or emergency, each person in the area should stay calm and listen for instructions from the on-sight supervisor. Given the unpredictable nature of horses, it is best for everyone to remain still and silent unless it is necessary to move out of harm’s way.

I certify I have read the RULES FOR PARTICIPANTS:

Yes

IDAHO EQUINE ACTIVITIES IMMUNITY ACT (required)

Please confirm you have read the IDAHO EQUINE ACTIVITIES IMMUNITY ACT at the end of this section.

Equine Activities Immunity Act 6-1802 Limitation of Liability on Equine Activities

(1) Except as provided in subsections (2) and (3) of this section, an equine activity sponsor or an equine professional shall not be liable for any injury to or the death of a participant or equine engaged in an equine activity and, except as provided in subsections (2) and (3) of this section, no participant nor participant’s representative may maintain an action against or recover from an equine activity sponsor or an equine professional for an injury to or the death of a participant or equine engaged in an equine activity.

(2) The provisions of this chapter do not apply to the horse or mule racing industry a regulated in chapter 25, title 54, Idaho Code.

(3) Nothing in subsection (1) of this section shall prevent or limit the liability of an equine activity sponsor or an equine professional:
(a) If the equine activity sponsor or the equine professional:
(i) Provided the equipment or tack and the equipment or tack caused the injury; or
(ii) Provided the equine and failed to make reasonable and prudent efforts to determine the ability of the participant to engage safely in the equine activity, determine the ability of the equine to behave safely with the participant, and to determine the ability of the participant to safely manage the particular equine.
(iii) Owns, leases, rents or otherwise is in lawful possession and control of the land or facilities upon which the participant or equine sustained injuries because of a dangerous latent condition which was known to or should have been known to the equine activity sponsor or the equine professional and for which warning signs have not been conspicuously posted.
(iv) Commits an act or omission that constitutes willful or wanton disregard for the safety of the participant or equine and that act or omission caused the injury.
(v) Intentionally injures the participant or equine. (b) Under liability provisions as set forth in the products liability laws; or (c) Under the liability provisions set forth in chapter 9, title 6, Idaho Code.

I certify I have read the IDAHO EQUINE ACTIVITIES IMMUNITY ACT:

Yes

Application for Admission to Champ’s Heart Program

Participant's Birth Year

Participant's Height?

Participant's Weight in lbs?

Participant's Gender

Parent/Guardian/Caregiver Information

Additional Information

How did you hear about Champ's Heart?

Has your child ever been around a horse before?

Has your child ever ridden a horse?

Yes No

It is important for us to understand the expectations that you and your child have for his/her experience. Please check all of the following options that are of interest:

Ride a horse Play games on horseback Just want child to have fun… a time out from emotional/physical stressors Pet, groom, or engage in other ground activities Other

Please list your child’s physical strengths:

Please list any physical limitations that may affect your child’s ability to safely interact with or ride a horse. Include issues with mobility, core strength, and diagnoses that may increase his or her risk of sustaining injury (e.g., seizure disorders, spinal issues, cerebral palsy, etc.). Please note that these conditions won’t necessarily preclude your child from being able to ride. However, depending on the condition, a physician’s referral may be required.

Please list your child’s social abilities:

Please list any cognitive limitations, behaviors, or social difficulties that we should be aware of to best assist your child:

Specific Considerations:

Does your child have a history of seizures?

Yes No

If yes, what type of seizures are they?

If yes, are the seizures well controlled with medication?

Yes No

Please list any special needs or considerations regarding your child (e.g., issues with a specific stimulus, or sensory issues that our staff should know about while interacting with your child).

Is there anything else we should be aware of when interacting with your child?

Photo Release of Participants

Champ’s Heart, and anyone authorized by Champ’s Heart, has my irrevocable consent to use my likeness, name, voice, or words in either television, radio, newspaper, magazine, social media, and other media, in a form, for the sole purpose of advertising or communicating the purposes and activities of Champ’s Heart. I understand that I will receive no compensation and that all photographs and video shall be the sole property of Champ’s Heart.

Yes No

Childrens Program Hours

Monday 2PM – 8PM

Thursday 10AM – 8PM

Saturday 9AM – 6PM

Veterans Program Hours

Friday 10AM – 2PM

See our Privacy Policy Here