Reasonable Adjustment Application Form

Reasonable Adjustment Application Form

Help us to understand your special needs and what we can do to help you fully immerse yourself at Pony Club events and activities.
Rider's Full Name:*

First NameLast Name
YesNo
Name of Parent / Guardian *

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Rider's Address*

Street Address

Street Address Line 2

CityState

Post Code
Select Rider's state*
This is because the application is sent to an authoriser in the rider's state
State email address
example@example.com
YesNo
Pony Club membership ID*
Nature of the disability *
Date of onset of disability (if applicable)

DayMonthYear
Cause of disability*
StableDegenerativeOther
Medical verification of the disability is required. A Doctor, Specialist or Allied Health Professional's Certificate, giving their assessment of the nature of the disability and the amount of functional ability which the person retains is required. Please attach this document below. *

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Please advise the rider's present level of competition or if they intend to ride at rally/days only *
Please list any compensating aids or adaptive equipment used by the applicant. *
Please detail any special equipment, saddlery or aids.
REASONABLE ADJUSTMENT DETAILS
Allow us to understand what adjustments you would like to see that would help to accommodate your inclusion in Pony Club events and activities. Please list all requests or requirements.
Note: An exemption will not be granted if it:

         *           gives any rider an unfair advantage over other competitors

         *           adversely affects the safety of the rider

         *           adversely affects the welfare or well-being of the horse
Please attach any additional documents

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Signature *

Clear
Signature of Parent/Guardian*

Clear
Should be Empty:

Reasonable Adjustment Application Form

REASONABLE ADJUSTMENT DETAILS