PVS Training Client Details Form

Riders Full Name *

First Name Last Name

Parent/Guardian Name (if under 18)

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

E-mail

example@example.com

Date of Birth

Date

Rider Height

Only required for school horse lessons

Rider Weight

Only required for school horse lessons, so that we can match the rider and horse together correctly.

Photo Release *

I consent I do NOT consent

to the use and reproduction by Windrush Farm Therapeutic Equitation, Inc. of any and all photographs and any other audio-visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.

How did you hear about us? *

Do you have any previous riding experience?

No Experience I have had a few lessons/rides I can walk I can trot I can canter I am an experienced rider

Emergency Contact Name *

Emergency Contact Number *

Do you have any medical conditions *

Yes No

If 'Yes' please provide further information below

Do you have any physical function limitations?

Please let us know if you have any limiting physical conditions that may affect your riding. i.e. mounting, partial nerve damage to one side, frozen ankle etc

Do you have any cognitive learning impairments?

i.e.: learning disabilities, hearing aids, tools etc

Signature of Rider or Parent/Guardian if under 18yrs *

Clear

To the best of my knowledge the above information provided is up to date and accurate.

Client Details: