BOOKING ENQUIRY FORM
HORSE RIDING
ENQUIRY TYPE
*
Pony Camp
Group Lesson
Private Lesson
Stable Management Lesson
Private Group Lesson
Therapeutic Riding Lesson
BHS Pathway Lessons
Pony Club
CONTACT DETAILS
Riders Name
*
First Name
Last Name
Riders DOB
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
County
Eircode
Phone Number Parent/ Guardian (If under 18)
*
-
Area Code
Phone Number
Parent/Guardian Name
*
Gender
*
Height
*
Weight
*
Email Address
*
example@example.com
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Next
RIDING HISTORY
*
Therapeutic Riding
Never ridden before
Has ridden 1-5 times
Riding with the assistance of a leader
Trotting with stirrups without a leader
Trotting without stirrups
Cantering
Riding over jumps 30-40cm
Riding over jumps 50 - 60cm
Riding over jumps 70-80cm
Riding over jumps 80cm +
Riding over cross country jumps
Please give details of previous experience, providing as much information as possible (e.g. riding lessons weekly for six months, has own horse etc.)
*
Details of last time ridden horse/ attended a lesson:
*
Has the applicant completed any riding assessments? (e.g. AIRE Amateur Assessment, Pony Club or BHS) If so please give details:
*
Day's & Times applicant is available to attend lessons:
Monday
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Tuesday
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Wednesday
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Thursday
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Friday
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Saturday
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Back
Next
RIDING HISTORY
Has the applicant been diagnosed with a medical condition/ disability?
*
Yes
No
If you answered yes, please give details:
Has the applicant ever had epileptic episodes?
*
Yes
No
If you answered yes, when did the last one occur?
Please give details:
Does the applicant have any physical difficulties in any of the following areas? Mobility, balance, posture, does the applicant wear orthopaedic supports – e.g. back brace, splints etc.
*
Yes
No
If you answered yes, please give details:
Does the applicant need a hoist?
*
Yes
No
Does the applicant have any sensory difficulties? Sight, sound, smell, touch, taste, vestibular?
*
Yes
No
If you answered yes, please give details:
Does the applicant have any psychosocial difficulties: social interaction, self-esteem, mood disorder – depression, anxiety, OCD etc.?
*
Yes
No
If you answered yes, please give details:
Does the applicant have any allergies that we need to be aware of?
*
Yes
No
If you answered yes, please give details:
Applicants Signature Parent/Guardian Signature (If under 18)
Submit
Should be Empty: