Participant Information Form RDA Brigadoon

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 Details

Name of person completing this form *

I am a new participant to an RDA ProgramI have participated in an RDA Program before and wish to renew

First Name *

Last Name *

Preferred name (if different)

Date of Birth *

Gender *

FemaleMaleNon-BinaryPrefer not to say

Primary contact name *

Primary Contact Phone Number *

Primary contact email address *

Participant Height *

Participant Weight *

Does the participant have a disability/diagnosis? *

YesNo

Please provide detail of the disability/diagnosis *

Please describe other *

Participant Medical Information

The following questions are asked to ensure that the correct RDA program and/or horse is allocated for the participant. If you need any clarification or assistance with answering the following section, please contact us at admin@rda.org.au.

Please provide the full nature of medical diagnosis that was not listed as a disability diagnosis above including all secondary conditions e.g. diabetes *

Does the participant have any of the following?

Impaired hearing *

YesNo

Impaired speech *

YesNo

How does the individual currently communicate (please tick all that apply): *

Spoken language (phrases and sentences)Spoken language with limited ability to use language functionally to get needs metNon-speakingUses gestures/body language/sign language to communicateUses AAC (e.g. visuals, communication boards, AAC device)

Impaired balance *

YesNo

How do you rate the individuals balance? *

Poor (unable to balance independently) Moderate (can stand unaided)Good (can stand on one leg)Great (Can ride a two wheel bike)

Impaired functional capacity *

YesNo

We require further information relating to the individual’s functional capacity. Can the individual do the following?

Get in and out of a car? *

Independently With assistance

Walk up and down steps: *

Unaided Holding the rail With assistanceCannot use stairs

Hold a pencil? *

YesNo

Put their own socks on? *

YesNo

Does the individuals functional ability remain stable or does it change (fluctuate)? *

Is there any other information you think that the RDA Coach should know in order to make an initial assessment to match the individual with the appropriate horse and volunteer resources? *

Impaired Bladder / Bowel control *

YesNo

Please Provide Details *

Heart conditions *

YesNo

Please provide details *

Impaired vision *

yesNo

For how long has the individual had impaired vision? *

Is there a medical diagnosis related to impaired vision? *

Yes No

Please provide detail of the medical diagnosis *

Are there factors that make eye or vision problems better or worse? *

YesNo

Please give detail of these factors *

Fainting turns

YesNo

Please provide details *

Respiratory conditions *

YesNo

Does physical activity effect this respiratory condition *

YesNo

Please provide details *

Are there any environmental conditions that can affect this respiratory condition? e.g. dust? *

YesNo

Please provide details *

Inflammation or pain in joints *

YesNo

Does physical activity effect this condition *

YesNo

Please provide details *

Changed muscle tone *

YesNo

Please provide information on which muscle groups are affected and the change in tone experienced *

Impaired circulation/pressure sores *

YesNo

Please provide details of where any pressure sores are/have been present and what interventions are used to enable better comfort. *

Drainage devices (shunt, gastronomy, colostomy, feeding button etc) *

YesNo

Please describe the type of drainage device (shunt, gastronomy, colostomy, feeding button etc) and any relevant detail. *

Use of splints, braces (external), prostheses *

YesNo

What is the type of splint, brace (external) or prostheses and which limb(s) is/are affected: *

Please describe what "other" area would you like the program to focus on.

Contra-indications and Implications for Participation of RDA Programs

The following medical conditions are identified as high risk for people involved in horse riding. RDA Australia is committed to providing the safest possible service to our participants and we are unable to do this for people with the following diagnosed conditions.

Other activities may be suitable, The RDA centre will contact you to discuss if there is an available program.

Please tick where the participant has any of these conditions.

Atlanto Axial Instability (unstable neck and/or spine)HemophiliaAny condition that causes a higher risk of fractures such as: Osteo Genesis Imperfecta (OGI), Brittle Bones, Severe Osteoporosis, Any other pathological fracturesUncontrolled Tonic Clonic SeizuresUncontrolled Tonic or Atonic SeizuresUnstable spine with high risk of neurological damage or subluxation

Atlanto Axial Instability (AAI) / Down Syndrome

AAI is the instability, sublaxation or dislocation of the joint between the first and second cervical vertebrae. This is a potentially life-threatening condition common to Down Syndrome. Specific X-rays may be needed to rule out this instability before riding is permitted. Groups or physicians should not rely on X-rays taken before the age of 3 years (even up to 5 years) as the area involved has not ossified at this early age. Films obtained just prior to riding are advisable. RDA Australia recommends that all riders with Down Syndrome be examined by a physician who is briefed on the nature of AAI before completing the RDA Medical Practitioner Consent Form.

Pre-cautions for participants with Down Syndrome

Excessive head and neck movement during riding could cause repeated small injuries to the cervical spine. This in turn could lead to increased instability of the head and neck and pressure symptoms could occur. If a rider were to fall from a horse, which can occur even though all precautions are taken, and AAI is present, severe damage to the spinal cord or death could occur. All riders with Down Syndrome are strongly recommended to have a full assessment before commencing riding. If riding is approved by a physician, parents/riders must report any neurological symptoms if they occur e.g. headaches, dizziness, nausea in motion, blurry eyes, loss of head control, loss of hand control, change of gait, bladder or bowel function and these should be investigated by your Medical Practitioner before riding continues. RDA Coaches will monitor the amount of head movement and neck stability during riding and will adapt activities until muscles develop to appropriately support the head and neck.

Pre-cautions for participants with Epilepsy

RDA can cater programs for participants with Absence and/or Partial Seizures by providing additional support structures. Participants with a history of Tonic Clonic or Atonic Seizures should have their condition controlled by medication before participating in RDA programs. In the unexpected event that a participant experiences a seizure during the RDA program, RDA coaches and volunteers are trained in emergency dismount procedures and seizure management. Participants should not participate in horse related activities if they have suffered a Tonic Clonic or Atonic seizure within the past 24 hours.

The following medical conditions may have implications for people involved in horse riding. RDA Australia is committed to providing the safest possible service to our participants and we rely on a Medical Practitioner’s opinion and disclosure of any medical conditions that should be considered for involvement with horse riding/ horse related activities.

A Medical Practitioner Consent Form will be sent to you by the office who is managing your application.

Please tick if the participant has any conditions relating to below

Down SyndromeSpinal Fusion or External Spinal Braces Scoliosis Asthma/AllergyEpilepsy Conditions where sitting astride a horse may cause pain or hip dislocation.Conditions where joints may not sustain repetitive movements.Severe allergies or asthma that may cause anaphylaxis reaction (dust, pollen or animal hair).Spinal fusion with internal fixations.

Atlanto Axial Instability (AAI) / Down Syndrome

AAI is the instability, sublaxation or dislocation of the joint between the first and second cervical vertebrae. This is a potentially life-threatening condition common to Down Syndrome. Specific X-rays may be needed to rule out this instability before riding is permitted. Groups or physicians should not rely on X-rays taken before the age of 3 years (even up to 5 years) as the area involved has not ossified at this early age. Films obtained just prior to riding are advisable. RDA Australia recommends that all riders with Down Syndrome be examined by a physician who is briefed on the nature of AAI before completing the RDA Medical Practitioner Consent Form.

Pre-cautions for participants with Down Syndrome

Excessive head and neck movement during riding could cause repeated small injuries to the cervical spine. This in turn could lead to increased instability of the head and neck and pressure symptoms could occur. If a rider were to fall from a horse, which can occur even though all precautions are taken, and AAI is present, severe damage to the spinal cord or death could occur. All riders with Down Syndrome are strongly recommended to have a full assessment before commencing riding. If riding is approved by a physician, parents/riders must report any neurological symptoms if they occur e.g. headaches, dizziness, nausea in motion, blurry eyes, loss of head control, loss of hand control, change of gait, bladder or bowel function and these should be investigated by your Medical Practitioner before riding continues. RDA Coaches will monitor the amount of head movement and neck stability during riding and will adapt activities until muscles develop to appropriately support the head and neck.

Pre-cautions for participants with Scoliosis

Scoliosis is a lateral curvature of the spine with a rotatory component. An Orthopaedic Surgeon should provide information about the degree and location of the scoliosis. When the mobility of the spine is an issue, the physician needs to evaluate the spine to determine if there is enough functional mobility to ride a horse. If there is insufficient flexibility in the spine to accommodate the movement of the horse, the physician should indicate that RIDING IS NOT RECOMMENDED. If riding is approved, RDA Coaches will attempt to provide as centred, and balanced position on the horse as is possible to assist with the improvement of core strength and muscle development to support the spine.

Please give detail of the individuals condition

Please upload your medical condition management plan (if you have one)

Browse

Participant Social, Emotional and Sensory Information

Does the person overreact to sensory input? (they become overwhelmed and may avoid the input) *

YesNo

Please provide more detail *

Does the person underreact to sensory input? (they may seek out more input) *

YesNo

Please provide further detail *

Does the individual display behaviors of concern? (Please note: this is to allow us to best allocate and support the individual within our programs) *

YesNo

Please provide further information *

For the behaviours selected above, where do they typically occur? (select all that apply) *

HomeSchool/Day options programCommunityOther

Other - Please specify *

What restrictive practices are currently being implemented (if any)? *

Does the individual have a Behavior Management Plan? *

YesNo

Please upload plan *

Browse

I have read and understood the Privacy Collection Notice *

I warrant that all information provided by me herein is true and correct and 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. *

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

YesNo

Parent/Legal Guardian full name *

Legal Guardian full name *

Parent/Legal Guardian Signature *

Draw signature|Type signatureClear

Legal Guardian Signature

Draw signature|Type signatureClear

Signature *

Draw signature|Type signatureClear

Name *

I'm Not a Robot *

Cal

Save and Complete Later