Connections Equine Therapy Walk On!
CONNECTIONS
Equine Therapy
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Equine Assisted Therapy Application

Welcome to Connections Equine Therapy Program!

All new and returning clients will need to fill out our new online application form (further down on this page).  We apologize for the 'paperwork'.   Most of the information is mandated by insurance and the rest we need in order to serve you well.

This year, due to an avalanche of new expenses and mounting costs we anticipate our budget will run well over $100,000.    Connections is supported strictly by donations.  We receive no state or federal assistance.   For this reason, we need assistance and support from our client families to keep this program going and growing.

If you are returning to Connections we can’t wait to see you again!

If you are new to the program we are so anxious to meet you and your loved ones and welcome you into the Connections Family!

We welcome all to get involved with life here at the ranch.  There are many volunteer opportunities for family members and our scholarship committee looks very favorably on such involvement when granting scholarships.

Happy Trails,

Andrea Baldwin, Director


2015/2016 Calendar

2015

Sept 21- Deadline for submission of Client Applications for Session 1

Sept 29 - Volunteer Training

Oct 5 – 9 – Intake Week (Interviews/orientation for new clients)

Oct 12 – Nov 13 -  Session 1- (5-weeks)

Nov 6 – Deadline – Submission of Client Applications for Session 2 (New clients only)

Nov  16 -  Dec 18 - Session 2 - (5-weeks)

(No Horsemanship Classes Nov 26 & 27 - Thanksgiving

Dec 18 - Deadline – Submission of Client Applications for Session 3 (New clients only)

Dec 18 – Jan 3 - CHRISTMAS BREAK

2016

Jan 4 – 8 – Intake week

Jan 5 – Volunteer Training

Jan 11 – Mar 4  - Session 3

Feb 26 - Deadline – Submission of Client Applications for Session 4 (New clients only)

Mar 7 – 11 – Down/Intake Week

Mar 8  – Volunteer Training

March 14 – May 6 – Session 4

April 29 - Deadline – Submission of Client Applications for Session 5 (New clients only)

May 9 - 13  – Down/Intake Week

May 10  – Volunteer Training

May 16 – June 24 – Session 5

 

CLICK HERE FOR PRINTABLE APPLICATION FORM 


Page 1 of 10

EQUINE ASSISTED THERAPY APPLICATION
GENERAL INFORMATION
First Name *
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Age *
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Weight *
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Street Address *
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State *
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Primary Phone *
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Parent or Guardian *
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Alterante Phone
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Ethnicity (for grant purposes) *
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Are you a Veteran
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Last Name *
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Birthdate *
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Height *
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Sex *
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City *
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Zip Code *
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E-Mail *
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Relationship *
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Employer/School
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How did you hear about us?
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THERAPEUTIC INFORMATION
Diagnosis *
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Medications
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Seizures
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Ambulation
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Amputation
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Prosthesis
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Physical Limitations
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Learning Style
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Hearing
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Behavior Issues
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PLEASE RATE THE FOLLOWING ON A SCALE OF 1-5
(1=Poor, 5=Excellent)
Attention Span
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Standing Posture
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Gross Motor (hands)
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Fine Motor (hands)
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COMMUNICATION SKILLS
Understanding
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EDUCATION
Reading Level
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Picture Recognition
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Date of Last Seizure
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Description
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Description
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Vision
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Description
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Sitting Posture
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Balance
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Gross Motor (overall)
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Fine Motor (overall)
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Expressive
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CountsTo
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Alphabet
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SOCIAL, DEVELOPMENTAL, PSYCHOLOGICAL FUNCTION
Check all applicable issues.





































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Details/Notes
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CONNECTIONS EQUINE THERAPY POLICIES
Please read all of the following and indicate your acceptace at the end. We want to make your experience at Connections worthwhile. Your compliance with these policies helps us make it so for all!
APPLICATION FORM
All forms must be completed and submitted prior to the first session. All returning participants must complete an application annually.
SCHEDULING
Scheduling is on a first come first serve basis. We group participants together by skill level, age, and availability. Riders participate in minimum one time per week for each session. When a NEW PARTICIPANT completes this application, they will be scheduled for a NEW PARTICIPANT INTAKE and tour of the facility. Once the intake evaluation is complete the proper placement of the participant will be scheduled. RETURNING PARTICIPANTS will be scheduled once their application has been submitted. Class times are on a first come first serve basis, so it is important to complete all forms promptly.
CANCELLATIONS
When clients enroll for a session there will be no refunds for sessions missed unless Connections cancels. Weather is unpredictable in Arizona, and it is sometimes unsafe to conduct classes outdoors. In such cases, appropriate indoor sessions will be conducted and the regular session charge will still apply. Connections reserves the right to cancel classes due to weather, unavailability of horses, volunteers, or instructor, etc. Credit will be issued for such cancellations.
LATE ARRIVALS
We will wait 10 minutes past the scheduled session time. Please let us know if you are going to be late, horses will be put away after this 10 minute period and will not be available. NO credit will be issued/NO make-up time scheduled.
DRESS CODE
Close-toed footwear with a closed back is mandatory for all participants.
PAYMENT POLICY
Fees for the full session are due before the beginning of that session. Normal fee for Equine Assisted Therapy sessions is $120 per appointment. Our fees are on a sliding scale and full and partial scholarships are available. If you need financial assistance, please fill out the Scholarship Application Form further on in this application. Clients with an unpaid balance will not be able to register for further sessions.
HORSES
Do not feed or pet any of the horses. Our animals are on special diets and you may interfere with their health. In addition, unsupervised feeding of animals may result in injury. Please do not go into the barn area without a staff member, instructor or trained volunteer.
PETS
We have a high commitment to safety for our participants and horses. Therefore, NO pets are allowed on the premises. Exceptions are certified companion or working therapy support animals, proof of certification/training must be provided.
EQUINE ACTIVITY LAW
Warning: Under Arizona Law, an equine activity sponsor or equine professional is not liable for any injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities, pursuant to A. R. S. s 12-553.
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I HAVE READ AND UNDERSTAND THE POLICIES ABOVE AND WILL COMPLY WITH THEM.
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Initials/Date *
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WAIVER, RELEASE OF LIABILITY, INDEMNITY AND EXPRESS ASSUMPTION OF RISK AGREEMENT - ARIZONA
READ CAREFULLY BEFORE SIGNING
I agree to this Waiver, Release of Liability, Indemnity, and Express Assumption of Risk Agreement with Connections Equine Therapy Program who is a corporation or LLC (hereafter referred to as “Stable") as a condition for his/her/its/their allowing me and the persons identified below (if any), to do any or all of the following at any time and at any location: enter Stable’s premises, land, facilities, barns, arenas, paddocks, pastures, and surrounding land; be near horses, ponies, mules, or donkeys (hereafter, “equines”), work with, handle, ride, drive, and/or receive instruction or guidance related to riding, driving, handling and/or working with equines. (All of these activities, individually and collectively, will be referred to as “The Activities” throughout this document.) To the fullest extent allowed by law, I also make this agreement on behalf of the following who are my child/children or legal ward(s). All parts of this document apply to me and each of the children or legal wards listed above. [We will collectively call ourselves "I," "me," or "my" throughout this document.]
IT IS AGREED AS FOLLOWS:
1. I understand that although I am signing this document today, I intend for it to be valid and binding now and at all times in the future when I engage in any or all of The Activities at any time and any location.
2. Risks. I understand that anyone riding, driving, handling, working with, or even near an equine at any location can suffer bodily and other injuries. Among other things, equines are unpredictable by nature. For example, when frightened, angry, or under stress, the natural instincts of an equine are to jump forward or sideways, back up quickly, or run away from real or perceived danger by trotting or galloping. Equines also have the ability to kick, buck, rear up, spin around, strike, or bite. I know that equines can do these and other things without warning. I also understand that all equines, even if they have no history of hurting anyone, are powerful and have the potential to be dangerous to people, equines, and other animals. I also understand that riding, driving, handling, working with, or even being near an equine can expose me to numerous hazards, which could include, for example: the propensity of an equine to behave in ways that may result in injury, harm, or death to persons on or around them; the unpredictability of an equine’s reaction to sounds, sudden movements, and unfamiliar objects, persons, or other animals; certain hazards such as surface or subsurface conditions on land; and/or collisions with other equines, animals, or objects. I understand these risks and dangers that are inherent in equine-related activities, and I agree to assume all of them. I also understand that these are just some of the risks, and I agree to assume others that are not mentioned in this document. I am NOT relying on Stable to list all possible equine-related risks in this document or at any time.
3. WAIVER, LIABILITY RELEASE, AND EXPRESS ASSUMPTION OF RISK: As consideration for being allowed to engage in any or all of The Activities, now and in the future and at any location, I (on behalf of myself and my spouse, parents, heirs, representatives, assigns, minor children or legal wards) agree to each of the following:
(a) I am aware of the inherent risks associated with equine activities, some of which have been described above; (b) I agree to accept full responsibility for my own safety and welfare at all times before, during, and after engaging in The Activities. I agree to assume full responsibility for any and all bodily injuries, losses, expenses, or damages that I may sustain when engaging in The Activities at any time and at any location; (c) to the fullest extent allowed under Arizona law, Stable and his/her/its/their respective officers, directors, members, managers, employees, agents, heirs, family members, assigns, representatives, affiliated persons, and others acting on their behalf (hereafter referred to collectively as “The Released Parties”) shall not be liable for any losses, injuries, or damages that I may sustain as a result of engaging in any of The Activities at any time or at any location; and (d) I/we fully and forever release, waive, and discharge all claims, demands, damages, legal actions, causes of action, or rights of action (present or future) against The Released Parties whether or not the claims are known, unknown, anticipated or unanticipated, and whether or not caused by their ordinary negligence or other legal liability resulting from or arising out of my/our engaging in The Activities at any time and at any location. The term "damages" means, for example, medical costs, claims or losses because of bodily injuries, mental/emotional injuries, property damages, death, expenses, and/or personal property damages. This document is intended to apply and be binding regardless of whether I/we am/are riding, driving, handling, or near equines. In accordance with Arizona law, this document shall not apply if my injuries or damages resulted from Stable’s gross negligence or willful, wanton, or intentional acts or omissions.
4. INDEMNIFICATION. To the fullest extent permitted by law, I also agree to indemnify and hold harmless The Released Parties against any and all claims, demands, actions, liabilities, losses, or suits that are brought against The Released Parties (or either of them) which are in any way connected with my/our participation in any of the Activities at any time and at any location, including claims that allege acts or omissions of The Released Parties that are negligent or in violation of a state Equine Activity Liability Act. This indemnification shall also include reimbursement of reasonable attorney fees incurred by Stable or by others on its behalf.
5.ASTM/SEI Helmet/Headgear. I understand that I should purchase and wear properly fitted and secured ASTM-standard/SEI-certified protective headgear that is designed for use when riding, driving, or near equines. I am NOT relying on Stable to provide a helmet for me, to check any helmet or strap that I may wear, or to monitor my compliance with this suggestion at any time. If I choose to wear a helmet, if I choose not to wear a helmet, and the type of helmet I may wear are my decisions.
6. Arizona law applies to this document, and I agree that this document shall be enforced to the greatest extent permitted by law. If any clause conflicts with applicable law, only that clause will be null and void but the remainder shall stay in full force and effect. I agree to pay any attorney fees and costs for The Released Parties (or either of them) to enforce this Agreement, and I agree to indemnify and hold harmless The Released Parties for such fees and costs.
7. ALSO, I AGREE TO EACH OF THE FOLLOWING:
• I AM AT OR OVER 18 YEARS OF AGE;
• I AM OF SOUND MIND AND AM NOT SUFFERING FROM SHOCK OR UNDER THE INFLUENCE OF ALCOHOL, DRUGS, OR INTOXICANTS THAT AFFECT MY ABILITY TO READ AND UNDERSTAND THIS DOCUMENT;
• I HAVE READ THIS ENTIRE DOCUMENT AND I FULLY UNDERSTAND IT;
• I INTEND FOR THIS DOCUMENT TO BE VALID AND BINDING TODAY AND AT ALL TIMES IN THE FUTURE;
• BY SELECTING 'I AGREE', I ACKNOWLEDGE THAT IF ANYONE IS HURT OR PROPERTY DAMAGED BY PARTICIPATION OF MYSELF AND/OR MY MINOR CHILD/REN IN ANY OF THE ACTIVITIES, I MAY BE FOUND BY A COURT OF LAW TO HAVE WAIVED MY RIGHT TO BRING A LAWSUIT AGAINST ANY OR ALL OF THE RELEASED PARTIES;
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PHOTO/VIDEO RELEASE
I understand that I consent to and authorize the use and reproduction of any and all photographs and any other audiovisual materials taken of me, my son/daughter or ward, for promotional printed material, educational activities, social media and exhibitions or for any use for the benefit of Connections.

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Initials/Date
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RISK MANAGEMENT STATEMENTS
I understand that Connections has designated business hours at which time staff are present on the property
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I understand that horses are not to be fed anything by hand. Hand feeding encourages biting and nipping.
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I understand that horses are unpredictable. They may kick, bit or step on me.
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Initials/Date
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CONFIDENTIALITY STATEMENT
Volunteers, participants, and their families have a right to privacy that gives them control over the dissemination of their medical and/or other sensitive information. Connections shall preserve that right of confidentiality for all individuals in its program.
I, by initialing below, acknowledge this policy and will abide by it.
Initials/Date
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AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize CONNECTIONS to:
1. Secure and retain medical treatment and transportation if needed.
2. Release participant records upon request to the authorized individual or agency involved in the medical emergency treatment
Name
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Birthdate
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Address
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City/State/Zip
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Cell Phone
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Receive Text?
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In the event that I cannot be reached please contact
Name
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Phone
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Relationship
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Name
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Phone
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Relationship
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Date
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NON-CONSENT PLAN
I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services or while being on the property of the agency.



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Non-Consent Procedure
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Non-Consent Signature (If rider is under 18, Parent Guardian must sign)

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Date
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SCHOARSHIP APPLICATION
Connections Equine Therapy Program is a non-profit organization. Participant fees are necessary to help defray the expense of our programs and cover only a small portion of the actual cost. Scholarships are available to applicants WHO COULD NOT OTHERWISE PARTICIPATE in the program. Scholarships are limited; and there are so many requests for assistance, we ask that you make every effort to pay your fair share of the fee so that there will be scholarship funds available for all who need them.
EQUINE ASSISTED THERAPY $120 PER APPOINTMENT
MINIMUM COMMITMENT - 6 - 8 WEEK SESSION PER PUBLISHED SCHEDULE
SELECT SCHOLARSHIP ASSISTANCE REQUESTED:
SCHOLARSHIP AMOUNT.................... AMOUNT YOU PAY






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Occupation - Participant/Parent/Guardian 1

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Occupation - Spouse/Parent/Guardian 2

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Party Responsible for Payment

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Address
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City/State/Zip
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Phone 1
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Phone 2
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Email
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Annual Gross Income from all Sources
Family Annual Gross Income
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+Participant's Gross Income
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=Total Annual Gross Income
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Is the participant claimed as a dependent on your tax return?

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Number of Family Members

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Are any other family members disabled?

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If Yes, Please Explain:
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Are there any unusual financial hardships we should consider?

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If Yes, Please Explain
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You will be notified as to the scholarship amount you have been awarded after careful review by the scholarship committee.





































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