Reins From Above Therapeutic Riding Center, Inc.
841 Wiggins Rd. 
Angier,  NC 27501
Phone: 919-6319294
Website: www.reinsfromabove.org

Participant’s Consent for Release of Information 
(Only Required for Participants with Disabilities) 
Date:__________________________________________________________________________

Client/Participant Name:_____________________________________________________________ 
Client/Participant Address:___________________________________________________________ 
Client Social Security Number:_____________________ Date of Birth:________________________ 
Please List All Current Primary Care Physicians, Therapists (occupational, physical, speech, or mental health professionals), Special Education Teachers, or other professionals who may have information relevant to the safety, health, training, or goals for this participant in a therapeutic riding program. Use the back of this sheet if necessary for additional information; 
Name of Professional	 Type of Professional 		Address 			Phone ___________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________

I hereby authorize any or all of the above-named professionals to release: medical histories; Physical Therapy, Occupational Therapy and Speech Therapy evaluations, assessments, and program plans; Classroom Individual Education Plans (I.E.P); and psychological/psychiatric histories, diagnoses, and evaluations to: Reins From Above Therapeutic Riding Center, Inc. for the purpose of developing a Therapeutic Riding Program for the client named above.  

(Parents/legal guardians must sign for children under 18 or wards of the court. Both parents/guardians must sign below if there is joint or shared custody.) 

Date:____________Signature:_______________________________Print Name:________________________________ 
                                                   (Client, Parent, or Guardian) 

Date:____________Signature:_______________________________Print Name:________________________________ 
                                                   (Client, Parent, or Guardian)