Rider referral Dunedin Group RDA
Request for Rider to participate in RDA program
Referral made by information below.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Organization name and Title
*
If parent please write parent
Signature
*
Clear
Rider information
This information is required to enable the RDA Group to consider whether they are able to accept the prospective Rider into their RDA program. All information supplied will be considered confidential, and stored and used in accordance with the Privacy Act 2020.
Rider name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Weight in KG
*
Height in cm
*
Gender
*
Please Select
Male
Female
Non Binary
Prefer not to say
Rider address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for referral
*
Disability/ health condition/other information
*
What would you like the rider to achieve from RDA
*
Parent/ caregiver to complete
I understand that: 1:This information is required to enable the RDA Group to consider suitability to participate in an RDA program. 2: If accepted, further medical or educational information can be supplied for safety and planning purposes. 3:Final acceptance will be at the discretion of the RDA Group, after consultation with other relevant people where necessary, and that referral does not guarantee entrance into a riding program.
Rider/parent/ caregiver legal name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email address for Rider/parent/ caregiver
*
example@example.com
Date
-
Month
-
Day
Year
Date
Rider/parent/ caregiver signature
Clear
Submit
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