Student Information/Waitlist

Student Information (Waitlist)

Five Hearts Therapeutic Horsemanship ~ 5101 Holland Church Rd. Raleigh, NC (919) 625-4406 ~ Email: FiveHeartsTH@gmail.com
Student's Name

First Name Last Name
Date of Birth:

MonthDay Year
Date
Diagnosis:
Precautions/Helpful Information:
Goals for student:
2nd Student's Name (if applicable)

First Name Last Name
Date of Birth:

MonthDay Year
Date
Diagnosis:
Precautions/Helpful Information:
Goals for Student:
Phone Number
Please enter a valid phone number.
Parent/Guardian's Name (if under 18)

First Name Last Name
Parent/Guardian Phone Number (if under 18)
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Emergency Contact/Phone #
Type of lessons you are interested in (Check all that apply):

Therapeutic Riding ($40/45 Min. Session)Therapeutic Ground School (No riding) ($30/30 Min. Session)"Makin' Strides" Ages 7-12 Monthly Event (Groups of 5 or more) ($40 each)"Unbridled" Youth Sessions (4 Sessions for teens 12-17 years old) (Scholarship)
How did you hear about us?
Five Hearts TH Barn Rules (Please Read):
1. No Smoking/Vaping anywhere on the premises
2. Clean up after yourself - EVERYWHERE!
3. Sign all required liability release forms
4. Volunteers must sign in/out
5. Use calm voices while in the barn and around horses
6. No running around horses
7. Take private conversations elsewhere
8. No profanity/inappropriate conversations
9. Wear modest/appropriate clothing
10. Closed toed shoes required around barn and horses
11. Helmets must be worn by anyone under 18 years old
12. Children under 12 must be supervised by an adult at all times
13. Turn off lights when not in use
14. Keep all gates closed
15. ALWAYS BE KIND!
What days would your child be available? (Check all that apply)

Monday - 5:30Tuesday - 5:30Wednesday - 5:30Thursday - 5:30Sunday - 10:00Sunday - 11:00Sunday - 12:00
How often would you like your child to attend? ($40/session)

Once a monthTwice a monthOnce a week
Should be Empty:

Student Information (Waitlist)