Participant Acceptance Form RDA BrookeValley Farm

Once this form is submitted, copies of this Form are to be kept by:

The RDA Centre
The Member State Office (where applicable)

A PDF copy of this form will be sent to the primary contact email address that is entered into this form.

Information contained in this Form will be reported for statistical purposes to Riding for the Disabled Association of Australia Limited (RDAA).

Name of person completing this form *

Relationship to participant *

Participant Personal Details

First Name *

Last Name *

Preferred name (if different)

Date of Birth *

Gender *

MaleFemaleNon-binaryPrefer not to say

Do you identify as *

AboriginalTorres Strait IslanderNeither

Primary contact phone number *

Primary contact email address *

Address

Street address

City

State

Postcode

Emergency Contact

Name *

Relationship *

Primary phone number *

Alternative phone number

Participant Booking and Billing Preferences

How will the services with RDA be funded? *

NDIS FundedSelf-FundedOther

Please describe 'other'

NDIS Number

NDIS Plan Start Date

NDIS Plan End Date

My NDIS Funds are:

Self-ManagedPlan-ManagedNDIA Managed

Please provide your Funding Category and Item line number (e.g., Access Community Social & Rec Activities 04_104_0125_6_1) *

Please provide your Plan Manager Details below:

Business Name: *

Contact Person: *

Email Address (for invoicing purposes): *

Please upload your NDIS plan here (optional)

Browse

What email address would you like invoices to be sent for RDA services? *

Kidsport Funding & Access All Areas (AAA) Pass

Kidsport Funding

Eligible participants (ages 5 – 18 years) may apply for Kidsport Funding to pay for the Annual Registration Fee. To see if you are eligible and to apply, please visit https://www.dlgsc.wa.gov.au/funding/sport-and-recreation-funding/kidsport

Access All Areas (AAA) Pass
Eligible participants of all ages who live in the City of Swan may apply for a AAA pass to pay for the Annual Registration Fee. Please see City of Swan Website for more information or email communitygrants@swan.wa.gov.au to apply.

Have you or will you apply for Kidsport Funding or a AAA Pass? *

YesNo

Please ensure you send your Kidsport Code or AAA Pass to accounts@brookvalleyfarm.org.au so we can process the voucher for you as soon as possible.

Photography and Videography Consent

I consent to photographs, videos and other images being taken of me during or in any way associated with my participation in RDA activities. I acknowledge that the photographs, videos and/or images are owned by RDA. *

YesNo

Photo permissions

My RDA Centre may use the photographs, videos and/or images for social media, marketing, promotional, training and/or other purposes.My RDA State (if I have one) may use the photographs, videos and/or images for social media, marketing, promotional, training and/or other purposes.RDA Australia may use the photographs, videos and/or images for social media, marketing, promotional, training and/or other purposes.

Declaration and Consent

National Insurance Program Summary and Guidelines for Participants and Volunteers

RDA Australia has worked with its insurance partners to develop an insurance program that will provide cover that will protect participants when they are injured, or a claim is made against them. These insurance solutions have been devised to ensure the sustainability of the RDA Activities nation-wide and maintaining alignment to our Vision and Values. The link below summarise the Insurance Cover and answer some frequently asked questions.

National Insurance Program Summary and Guidelines for Participants and Volunteers

Show Consent to Participate

Consent to Participate

By completing, signing and submitting this Form, I hereby apply for membership of Riding for the Disabled Association of Australia Limited (RDAA) and provide my written consent to participate in RDA Activities. In so applying and in consideration of my application for membership being accepted I acknowledge and agree that:

“RDAA” for the purposes of this membership application and declaration means and includes the Riding for the Disabled Association of Australia Limited, its Member States and Territories and RDA Centres and where the context so permits, their respective directors, officers, members, servants or agents.

If accepted I will be a member of the RDA Centre noted in Section 1 of this Form, its Member State (where applicable) and RDAA.

This document cannot be amended. If I do amend it, my application will be null and void. It will not be accepted by RDAA.

Insurance is in place that provides limited cover to me whilst I am performing or participating in any authorised or recognised RDAA activity (“RDA Activity”). (For insurance details contact RDAA Office.) I can, in my own interests, seek and obtain personal insurance over and above the cover provided by RDAA.

The RDAA Constitution is a contract between me and RDAA. I will be bound by it and any By-Laws made under it. For the avoidance of doubt, I acknowledge and agree to comply with the Constitution or Rules of Association and By-Laws of RDAA, my Member State (where applicable) and my RDA Centre, if my application is accepted. Where there is any inconsistency between the Constitution or Rules of Association of RDAA, the Member States or RDA Centres, the Constitution of RDAA will prevail.

Warning: Equestrian activities (including but not limited to recreational and therapeutic riding) can be inherently dangerous. Serious accidents can happen which may result serious injury. I have voluntarily read and understood this warning and accept and assume the inherent risks in riding (including but not limited to recreational and therapeutic riding, carriage driving and vaulting).

Exclusion of Liability: Except where provided or required by law and such cannot be excluded, I agree that it is a term of my membership (if accepted) that RDAA is absolved from all liability however arising from injury or damage however caused (whether fatal or otherwise) arising out of my membership and/or participation in any RDA Activity. I acknowledge that the services and benefits I receive under my membership are recreational services. Where I am a consumer, as defined by any relevant law, certain terms and rights may be implied into a contract for the supply of goods or services for my benefit. I acknowledge that these terms and rights, and any liability of RDAA flowing from them, are expressly excluded, restricted or modified by these membership terms and conditions.

Release and Indemnity: In consideration of RDAA accepting my application for membership I:

(a) release and forever discharge RDAA from all Claims that I may have or may have had but for this release arising from or in connection with my membership and/or participation in any RDAA Activity; and

(b) indemnify and hold harmless RDAA to the extent permitted by law in respect of any Claim by any person including but not limited to another Member of RDAA, arising as a result of or in connection with my membership and/or participation in any RDA Activity. In this clause 7 “Claim” means and includes any action, suit, proceeding, claim, demand, damage, penalty, cost or expense however arising but does not include a claim in respect of any action, suit, made by any person entitled to make a claim under a relevant RDAA insurance policy or any personal insurance held by the member.

Fitness to Participate: I declare that I am and must continue to be medically and physically fit and able to participate in any RDA Activity within my range of abilities. I am not and must not be a danger to myself or to the health and safety of others. I will immediately notify RDAA in writing through my RDA Centre or Member State (where applicable) of any change to my fitness and ability to participate. I understand and accept that RDAA will continue to rely upon this declaration as evidence of my fitness and ability to participate. I acknowledge that if I have or have had any medical condition or disability (eg. physical, intellectual, psychiatric or behavioural) I may be required to submit with this application a RDA Medical Practitioner Consent Form completed by a Medical Practitioner. Further, I acknowledge that RDAA may in its reasonable discretion require me to provide a RDA Medical Practitioner Consent Form completed by a Medical Practitioner even if I have declared that I do not have or have not had a medical condition or disability.

Medical Treatment: I consent to receiving any medical treatment that RDAA considers necessary or desirable during or as a result, whether directly or indirectly, of my participation in a RDA Activity. I also agree to reimburse RDAA for any costs or expenses incurred in providing me with medical treatment, including but not limited to Ambulance costs.

Privacy: I understand that the information I have provided herein is necessary for the objects of RDAA. I acknowledge and agree that the information will be disclosed by my RDA Centre to the Member State (where applicable) and RDAA and will only be used for the objects of RDAA and to provide me with membership services. I understand that I will be able to access my information through my RDA Centre and/or Member State (where applicable). If the requested information is not provided my membership application may be rejected.

Consent to Participate PDF

I have read, understood, acknowledge and agree to the declarations in this application, including the warning, exclusion of liability and release and indemnity, and warrant that if my application for membership is successful, I will abide by the policies and procedures of my RDA Centre, Member State (where applicable) and RDAA. I acknowledge that if accepted my membership will entitle me to all benefits, advantages, privileges and services of RDAA membership as they apply to me. I further warrant that all information provided by me herein is true and correct and acknowledge that a copy of this Form has the same legal effect as the original. *

I have read and understood the Privacy Collection Notice *

POLICIES, PROCEDURES AND CANCELLATION POLICY

RDA BrookValley Farm currently relies solely on Volunteers to ensure you receive the services it provides. This includes our coaches who need time to plan lessons and ensure we have the staff and horses available to assist with your session.

Please note, you must come to your session on time, late arrivals will be unable to join a session. We recommend you arrive at least 5 minutes before your session especially if you need boots and a hat which can be provided.

It is a requirement of our policies and procedures that participants provide a minimum of 48 hours' notice if they are unable to attend a scheduled session. However, we do appreciate that illness or injury can suddenly occur and we ask that you provide as much notice as possible so that our volunteers are not giving up their time unnecessarily.

With limited funding available through grants, RDA BrookValley Farm relies heavily on the income generated through the attendance of our participants to continue its operation. For this reason, no shows or late notices will incur a charge of the full-service fee. In addition, any more than two (2) missed sessions, with or without notice, each term may potentially forfeit your place and be offered to the first person on our waiting list, except where a medical certificate can be provided.

Working outdoors and with animals can make the work we do often unpredictable when considering the weather and the needs of our horses. We ask for your patience and understanding in the event we may need to delay or postpone sessions relating to these circumstances and we will endeavour to offer make up sessions during school holidays when possible.

If you require any assistance or have any questions completing the attached forms, please contact our office via admin@brookvalleyfarm.org.au and one of our friendly staff will assist you as soon as possible.

Does the participant have the capacity to make informed consent? *

YesNo

PARENT/LEGAL GUARDIAN CONSENT

(IN RESPECT OF A PARTICIPANT UNDER THE AGE OF 18 YEARS OR WHERE INFORMED CONSENT CANNOT BE PROVIDED).

I am the parent or legal guardian of the participant and warrant that I have read, understood, acknowledge and agree to the declarations in this application and conditions of membership under the policies and procedures of the participant’s RDA Centre, Member State (where applicable) and RDAA. I warrant that all the information provided herein is true and correct.

I expressly agree to be responsible for the participant’s behaviour and agree to personally accept the conditions set out in this application and declaration including the provision by me of a release and indemnity in the terms set out above.

PARENT/LEGAL GUARDIAN CONSENT

(IN RESPECT OF A PARTICIPANT UNDER THE AGE OF 18 YEARS OR WHERE INFORMED CONSENT CANNOT BE PROVIDED).

I am the parent or legal guardian of the participant and warrant that I have read, understood, acknowledge and agree to the declarations in this application and conditions of membership under the policies and procedures of the participant’s RDA Centre, Member State (where applicable) and RDAA. I warrant that all the information provided herein is true and correct.

I expressly agree to be responsible for the participant’s behaviour and agree to personally accept the conditions set out in this application and declaration including the provision by me of a release and indemnity in the terms set out above.

Parent/Legal Guardian full name *

Parent/Legal Guardian signature *

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Parent/Legal Guardian signature *

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Signature *

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Name *

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