All information provided on this form will remain strictly confidential, for use by relevant RDA personnel only, in compliance with the statutory requirements of the Data Protection Act 2018. It will be used to help us to understand any specific needs you may have and to support you. We will also use this information to contact you in relation to your activities with RDA - this may include sending you important information about your involvement in your RDA Group, or any other activities you may take part in within RDA.

Part 1 - Your Details (Participant)

First name*

Last name*

Nicknames

Preferred Pronouns

DOB*

Day

Month

Year

Sex

Primary Language if not English

Contact Number*

Address*

Postcode*

Email*

Do you have previous RDA Experience*

Yes

If yes, which group?

Are you joining us from a school. college, group or similar?*

Yes

If yes, please provide the name

Preferred Days*

Monday

Tuesday

Wednesday

Thursday

Friday

Flexible

Part 2 - Specific information about you

Which Service are you interested in participating in? (Riding, Carriage driving or Equine Assisted Learning)*

Please tell us about your disability or impairment and how it affects you (to help us to understand how to support you)*

Do you have any conditions that may need special attention during your RDA activities? Is there anything else about your disability or impairment that we should be aware of, to help us to improve your RDA experience? *

In case we need to find out more about your disability and how we can support you, please provide the name and contact details of a medical professional, who knows you and is familiar with your medical condition(s)*

What's your height?*

What's your weight?*

Please note that the applicant’s height and weight details will be used discreetly by the group’s coach, to assess the suitability of available horses or ponies. Applicant’s height and weight may be reviewed periodically.

Part 3 - Additional Information

Please tick all that apply

Do you have any known allergies?

Do you have a visual impairment, or do you have low vision?

Do you have a hearing impairment, or do you have hearing loss?

Do you need any help with walking?

Can you walk up a few steps (e.g. up a mounting block to a horse)

Do you use any walking aids or supports?

Do you wear any orthopaedic appliances?

Are you a wheelchair user?

Can you take weight through your feet (e.g. sitting to standing)

Do you understand BSL and use it to communicate yourself?

Do you understand Makaton and use it to communicate yourself?

Would you prefer that we help you by using very simple instructions?

If you have answered YES to any of the above questions, please detail any additional information that you think would be helpful to us, to be able to help and support you, and give you the best experience we can

PARTICIPANT IN EDUCATION

Education Referral

Medical Referral

Parent Referral

Other

SEN

EHCP

Home

Refuse

Exclude

Comments

Part 4 - Declaration

· I wish to apply to join an RDA Group as a participant, and confirm that all details given on this form are true and accurate, to the best of my knowledge

· I agree that should the RDA Coach require additional information on my medical condition at any time, I will provide what is needed and will be willing to obtain a medical report from a medical professional, if necessary, who is familiar with my condition/s. I understand that I may be required to pay a fee for such a report.

· I confirm that I will notify RDA immediately if any of the details or information provided on this form should change in any way

· I recognise that this activity involves risk, and that I, the participant, must take all reasonable precautions and follow all advice properly given, at all times

· I understand that horses and ponies, by nature, are unpredictable and as such they may react to a situation or to the local environment in such a way that the rider/ vaulter/ carriage driver may be unseated by accident

In the absence of any negligence on the part of the RDA Group or RDA UK, I fully understand and accept that no liability will attach to either party.

I give my consent to photographs or videos of me being taken during RDA activities for training and/or publicity (including, but not limited to, websites, social media, newsletters and marketing materials for the RDA Group and RDA UK). I give this consent*

Yes

Would you like to stay updated with news via our Pony Express Newsletter?*

Yes

Signature - Participant / Parent / Guardian / Carer*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

If you are under 18 this form must also be signed by a parent or guardian.

Name

Relationship to Volunteer

Telephone Number

Address

The information provided on this form will only be used for the purposes stated above in relation to RDA volunteering activities.

Address

Postcode

We have a couple of spaces for under 16 yr olds in group sessions. Please complete this form if this applies to you! Many thanks

Part 1 - Your Details (Participant)

First name*

Last name*

Nicknames

Preferred Pronouns

DOB*

Day

Month

Year

Sex

Primary Language if not English

Contact Number*

Address*

Postcode*

Email*

Do you have previous RDA Experience*

Yes

If yes, which group?

Are you joining us from a school. college, group or similar?*

Yes

If yes, please provide the name

Preferred Days*

Monday

Tuesday

Wednesday

Thursday

Friday

Flexible

Part 2 - Specific information about you

Which Service are you interested in participating in? (Riding, Carriage driving or Equine Assisted Learning)*

Please tell us about your disability or impairment and how it affects you (to help us to understand how to support you)*

What's your height?*

What's your weight?*

Part 3 - Additional Information

Please tick all that apply

Do you have any known allergies?

Do you have a visual impairment, or do you have low vision?

Do you have a hearing impairment, or do you have hearing loss?

Do you need any help with walking?

Can you walk up a few steps (e.g. up a mounting block to a horse)

Do you use any walking aids or supports?

Do you wear any orthopaedic appliances?

Are you a wheelchair user?

Can you take weight through your feet (e.g. sitting to standing)

Do you understand BSL and use it to communicate yourself?

Do you understand Makaton and use it to communicate yourself?

Would you prefer that we help you by using very simple instructions?

PARTICIPANT IN EDUCATION

Education Referral

Medical Referral

Parent Referral

Other

SEN

EHCP

Home

Refuse

Exclude

Comments

Part 4 - Declaration

· I wish to apply to join an RDA Group as a participant, and confirm that all details given on this form are true and accurate, to the best of my knowledge

· I confirm that I will notify RDA immediately if any of the details or information provided on this form should change in any way

· I recognise that this activity involves risk, and that I, the participant, must take all reasonable precautions and follow all advice properly given, at all times

In the absence of any negligence on the part of the RDA Group or RDA UK, I fully understand and accept that no liability will attach to either party.

Yes

Would you like to stay updated with news via our Pony Express Newsletter?*

Yes

Signature - Participant / Parent / Guardian / Carer*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

If you are under 18 this form must also be signed by a parent or guardian.

Name

Relationship to Volunteer

Telephone Number

Address

The information provided on this form will only be used for the purposes stated above in relation to RDA volunteering activities.

Address

Postcode

RDA Application Information

RDA Group Name - Broadlands Equine Therapy & RDA

Charity Number - 117098

Group Contact Name - Paige Parsons

Contact Address - Lower Paice Lane, Medstead, GU34 5PX

Contact Email Address - office@broadlandsgrouprda.org.uk

Contact Telephone Number - 01420 375767

Part 1 - Your Details (Participant)

First name*

Last name*

Nicknames

Preferred Pronouns

DOB*

Day

Month

Year

Sex

Primary Language if not English

Contact Number*

Address*

Postcode*

Email*

Do you have previous RDA Experience*

Yes

If yes, which group?

Are you joining us from a school. college, group or similar?*

Yes

If yes, please provide the name

Preferred Days*

Monday

Tuesday

Wednesday

Thursday

Friday

Flexible

Part 2 - Specific information about you

Which Service are you interested in participating in? (Riding, Carriage driving or Equine Assisted Learning)*

Please tell us about your disability or impairment and how it affects you (to help us to understand how to support you)*

What's your height?*

What's your weight?*

Part 3 - Additional Information

Please tick all that apply

Do you have any known allergies?

Do you have a visual impairment, or do you have low vision?

Do you have a hearing impairment, or do you have hearing loss?

Do you need any help with walking?

Can you walk up a few steps (e.g. up a mounting block to a horse)

Do you use any walking aids or supports?

Do you wear any orthopaedic appliances?

Are you a wheelchair user?

Can you take weight through your feet (e.g. sitting to standing)

Do you understand BSL and use it to communicate yourself?

Do you understand Makaton and use it to communicate yourself?

Would you prefer that we help you by using very simple instructions?

PARTICIPANT IN EDUCATION

Education Referral

Medical Referral

Parent Referral

Other

SEN

EHCP

Home

Refuse

Exclude

Comments

Part 4 - Declaration

· I wish to apply to join an RDA Group as a participant, and confirm that all details given on this form are true and accurate, to the best of my knowledge

· I confirm that I will notify RDA immediately if any of the details or information provided on this form should change in any way

· I recognise that this activity involves risk, and that I, the participant, must take all reasonable precautions and follow all advice properly given, at all times

In the absence of any negligence on the part of the RDA Group or RDA UK, I fully understand and accept that no liability will attach to either party.

Yes

Would you like to stay updated with news via our Pony Express Newsletter?*

Yes

Signature - Participant / Parent / Guardian / Carer*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

If you are under 18 this form must also be signed by a parent or guardian.

Name

Relationship to Volunteer

Telephone Number

Address

The information provided on this form will only be used for the purposes stated above in relation to RDA volunteering activities.

Address

Postcode