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
Address
*
Street Address
Street Address Line 2
City
County
Eircode
Phone Number Parent/ Guardian (If under 18)
*
-
Area Code
Phone Number
Parent/Guardian Name
*
DOB
*
-
Month
-
Day
Year
Date
Gender
*
Height
*
Weight
*
Email Address
*
example@example.com
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Next
RIDING HISTORY
*
Therapeutic Riding
Never ridden before
Has sat on a horse
Riding on own in walk
Trotting with stirrups with a leader
Trotting with stirrups without a leader
Trotting without stirrups
Cantering
Riding over jumps up to 50cm
Riding over jumps above 50cm
Riding over jumps up to 75cm
Riding over Cross Country jumps
Details of previous experience: (e.g. attended lessons for six months, has own horse etc.)
*
Details of last time ridden horse/ attended a lesson: 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: