2026 Authorization ROI Therapeutic Horse Program Scholarship

1. Applicant

Applicant Name*

First NameLast Name

Applicant Date of Birth*

Date

2. Requesting Party

Name & Address: Springbrook (Therapeutic Horse Scholarship Committee) 105 Campus Drive, Oneonta, NY 13820

Relationship to individual or department and title: Therapeutic Horse Program Scholarship Committee

Purpose of request: TO COMMUNICATE WITH STAFF OF ATHELAS THERAPEUTIC RIDING, GOLDEN GAIT FARM, OR STABLE MOVEMENTS REGARDING PARTICIPATION IN THERAPEUTIC RIDING ACTIVITIES

Date of Request: 3/6/2026

Nature of information to be released: ATTENDANCE, SESSION SUMMARIES/PROGRESS NOTES, & BILLING FOR THERAPEUTIC HORSEBACK RIDING ACTIVITIES DURING the CALENDAR YEAR 2026

I understand that this information is confidential and protected from disclosure to any other party.

3. Authorization

Select one*

I hereby authorize Springbrook and the instructor/staff of ATHELAS THERAPEUTIC RIDING, GOLDEN GAIT FARM, OR STABLE MOVEMENTS to release the requested information needed for participation in the 2026 Therapeutic Horse Program. I understand I have the right to cancel my permission to release information at any time before it is released.I REVOKE or DO NOT authorize Springbrook and the instructor/staff of ATHELAS THERAPEUTIC RIDING, GOLDEN GAIT FARM, OR STABLE MOVEMENTS to release the requested information needed for participation in the 2026 Therapeutic Horse Program.

Applicant Name or Person Authorized to Act On Behalf of the Applicant*

Email of Applicant or Person Authorized to Act On Behalf of the Applicant*

example@example.com

Applicant Signature or Person Authorized to Act On Behalf of the Applicant *

Date of Authorization*

Date

Relationship/Title*

If Person Authorized to Act On Behalf of the applicant is signing, add address here:

4. Verification of Release

The signature and date will be completed by Springbrook staff if you are awarded a scholarship.

Name of Springbrook Staff Releasing Information

First NameLast Name

Signature of Springbrook Staff Releasing Information

___________________________________________

Date

_______________________

See Springbrook's Notice of Privacy Practices for information on how your information may be used.

https://www.springbrookny.org/wp-content/uploads/Notice_of_Privacy_Practices.pdf

If you have questions about privacy practices, please contact

Springbrook's Privacy Officer at 607-353-7272 x2100

105 Campus Drive Oneonta, NY 13820 ~ Fax: 607.286.7166 ~ www.springbrookny.org

Springbrook