MyImpactPage - Bendigo

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Account

Username

Required

Username must not start with space

Username must not end with space

Username must not have two or more spaces in a row

Password

Required

	Password needs to have at least 12 characters.
	Password needs to have at least one upper case character.
	Password needs to have at least one lower case character.
	Password needs to have at least one number.
	Password cannot be on a list of commonly-used passwords.

Confirm Password

Required

	Password needs to have at least 12 characters.
	Password needs to have at least one upper case character.
	Password needs to have at least one lower case character.
	Password needs to have at least one number.
	Password cannot be on a list of commonly-used passwords.

Name Fields

Salutation
Legal First Name
First NameRequired
Middle Name
Last NameRequired
Suffix
Pronouns

Address

Address line 1Required
Address line 2
CityRequired
Country Required
State / Province Required
Zip / Postal CodeRequired

Email Addresses

Email Address Required
Secondary Email Address

Phone Numbers

Required Please enter at least one phone number

Home Phone
Work Phone
Work Extension
Cell Phone
Phone Preference

Text Messaging

I want to receive text messages on my cell phone.
Cell Phone Number

Online Presence

X Username

Linkedin Profile URL
Instagram Username

Misc Fields

Date of Birth mm/dd/yyyyRequired
Region

ABOUT THE PARTICIPANT

Gender

Required

Participant Weight (kgs)

Required

Participant Height (cms)

Required

Does the participant identify as

PARTICIPANT REGISTRATION DETAILS

If form is being completed on behalf of the participant:

Name of individual completing this form on behalf of participant

Relationship to participant (eg self, parent, support coordinator etc)

EMERGENCY CONTACT DETAILS

Emergency Contact - Full Name

Required

Emergency Contact - Relationship

Required

Emergency Contact - Primary Phone Number

Required

Emergency Contact - Alternative Phone Number

AVAILABILITY

Before registering, please visit www.rdav.asn.au to view our Centres and their session details, including days, times, and activities.

Make sure the session schedule suits your availability before you complete your registration.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

PARTICIPANT ABILITIES

To assist our ability to support your needs please indicate if the following apply:

I am a returning participant

Please advise previous centre and last date attended:

Is the participant a wheelchair user

Can the participant get in and out of a car independently?

Can the participant walk up and down steps?

Can the participant hold a pencil?

Can the participant put their socks on?

Please provide participant's disability diagnosis (level of disability) and their goals for the program.

S2. PARTICIPANT MEDICAL INFORMATION

Please DO NOT complete the section below (ie. questions marked S2) until you have received an email from the Centre asking for further information.

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

Once this form is submitted, copies of this form are kept by the RDA Centre and the State Office where applicable. Information from this form are reported to the Riding for the Disabled Association of Australia Limited (RDAA) for statistical purposes.

Does the participtant have a disability diagnosis?

If yes, please indicate the nature of the disability/diagnosis

Please select all areas that you would like support through RDA Programs

Sensory Processing and Regulation

Social and Emotional Support

Gross Motor Skills

Fine Motor Skills

Independence Skills

Community Access

Other

S2. GENERAL PARTICIPANT MEDICAL INFORMATION.

Please advise if the participant has any of the following conditions and where indicated the degree it impacts them.

ONLY MARK CONDITIONS APPLICABLE TO THE PARTICIPANT.

IMPAIRED HEARING

If YES please provide additional details

IMPAIRED SPEECH

Uses spoken language (phrases & sentences)

Uses spoken language with limited ability to get needs met?

Non-speaking

Uses gestures/body or sign language to communicate?

Uses AAC (eg visuals, communication boards, AAC device etc)

IMPAIRED BALANCE

How would you rate the individual's balance?

IMPAIRED BLADDER OR BOWEL CONTROL

If YES please provide additional details

HEART CONDITIONS

If YES please provide additional details

IMPAIRED VISION

How long has the participant had impaired vision. If there is a medical diagnosis provide details

FAINTING TURNS

If YES, please provide details

RESPIRATORY CONDITIONS

Does physical activity affect this respiratory condition?

Are there environmental conditions that can affect this respiratory condition (eg dust)?

Please provide any extra details regading any respiratory conditions the individual may have

INFLAMMATION OR PAIN IN JOINTS

Does physical activity effect this condition? If YES, please provide details

CHANGED MUSCLE TONE

If YES, which muscle groups are affected, provide details

IMPAIRED CIRCULATION / PRESSURE SORES

If YES, provide details

DRAINAGE DEVICES (shunt, gastronomy, colostomy, feeding button, etc.)

If YES, describe the type of drainage device with relevant details

USE OF SPLINTS, BRACES, PROSTHESES

If YES, describe the type of splint, brace (external) or prostheses and which limb(s) are affected

Please detail the nature of medical diagnosis not listed above, include secondary conditions (e.g. diabetes)

S2. MEDICAL CONSENT FORM

If you have been asked to supply a medical consent form by the Centre, please upload this here.

Medical Consent Form upload (ONLY if required)

Form upload (ONLY if required)

S2. CONTRA-INDICATIONS AND IMPLICATIONS FOR PARTICIPATION OF RDA PROGRAMS - PART 1

The following medical conditions have been 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 participant has any of these conditions

Atlanto Axial Instability (unstable neck or spine)

Hemophilia

Conditions that causes a higher risk of fractures (e.g. Osteo Genesis Imperfecta (OGI), Brittle Bones, Severe Osteoporosis, other pathological fractures)

Uncontrolled Tonic Clonic Seizures

Uncontrolled Tonic or Atonic Seizures

Unstable spine with a high risk of neurological damage or subluxation

Please provide detail of the condition and a copy of the medical condition management plan if you have one

S2. CONTRA-INDICATIONS AND IMPLICATIONS FOR PARTICIPATION OF RDA PROGRAMS - PART 2

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 indicate if any of these conditions apply to the participant

Down Syndrome

Spinal Fusion or External Spinal Braces

Scoliosis

Asthma / Allergy

Epilepsy

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

If you checked any box in this section, please provide additional details of the condition

Management Plans

S2. PARTICIPANT SOCIAL, EMOTIONAL AND SENSORY INFORMATION

Please indicate where the participant is impacted by any of the conditions and provide detail on how they may react.

ONLY MARK CONDITIONS APPLICABLE TO THE APPLICANT.

Is the participant hypersensitive to sensory input (more sensitive)

How do they react? (e.g. become overwhelmed, avoids the input, withdraw)

Is the participant hyposensitive to sensory input (less sensitive)

How do they react? (e.g. they seek more input)

Displays of Concern, (e.g. hitting, biting, screaming, etc.)

Please provide details:

If the participant has a behaviour management plan, please upload a copy.

Further uploads if required

S3. PARTICIPANT ACCEPTANCE FORM

Please DO NOT complete the section below (ie. questions marked S3) until you have received an email notifying you of your acceptance into the program which formally offers you a place at an RDA Centre.

Name of person completing this part of the form

Relationship to the Participant

S3. PHOTOGRAPHY & VIDEOGRAPHY CONSENTS

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

The following may use the photographs, videos and/or images for social media, marketing, promotional training and/or other purposes

My RDA Centre

RDA Victoria

RDA Australia

2026 PARTICIPANT 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 to protect participants when they are injured, or a claim is made against them. These insurance solutions are devised to ensure the sustainability of the RDA activities nation-wide and to maintain alignment with our Vision and Values. This link summarises the insurance cover and provides answers to frequently asked questions.

https://www.howdengroup.com/au-en/rdaa-insurance-centre

Please review and sign the 2026 Participant Declaration and Consent. NOTE that you can NOT ride until this has been signed.

File upload (if electronic waiver can't be signed, scan and upload a printed version here)

S3. 2026 PARTICIPANT REGISTRATION PAYMENT

2026 PARTICIPANT REGISTRATION FEE - $250

This fee covers insurance and administrative costs. Your RDA Centre may also charge additional riding fees.

Payment Options

Pay now by credit card (preferred)

Please Click SAVE at the bottom of the page before following the credit card link to ensure form is submitted.

To pay by credit card click here - https://buy.stripe.com/aFa7sE8zMbASbxe4V44c802
Want to pay another way - call (03) 9258 4730
Request an invoice - supply email address below

Please include the participant’s surname and RDA Centre in payment references.

How will services with RDA be funded?

How will you be paying the 2026 Registration Fee

If paying by invoice, please provide the email address to send it to

Is this email address for yourself or for your provider

If the invoice email belongs to your provider, please provide their name

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