PVS Training Client Details Form

Client Details:
Riders Full Name*

First NameLast Name
Parent/Guardian Name (if under 18)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
Date of Birth

DayMonthYear
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 consentI 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 ExperienceI have had a few lessons/ridesI can walkI can trotI can canterI am an experienced rider
Emergency Contact Name*
Emergency Contact Number*
Do you have any medical conditions*

YesNo
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.
Should be Empty:

Client Details: