BOOKING ENQUIRY FORM
HORSE RIDING
ENQUIRY TYPE
*
Group Horse Riding Lesson
Private Horse Riding Lesson
Stable Management Lesson
Therapeutic Riding Session
BHS Pathway Lessons
Cherry Orchard Pony Club
EAL
Seasonal Pony Camps
Pony Stars
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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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
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7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Until
until
1
2
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5
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8
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10
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Tuesday
1
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5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Until
until
1
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5
6
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10
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:
Hour
00
10
20
30
40
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Minutes
AM
PM
AM/PM Option
Wednesday
1
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5
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7
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9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Until
until
1
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5
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10
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Thursday
1
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7
8
9
10
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12
:
Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Until
until
1
2
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10
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12
:
Hour
00
10
20
30
40
50
Minutes
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PM
AM/PM Option
Friday
1
2
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5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Until
until
1
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Hour
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10
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30
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Minutes
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PM
AM/PM Option
Saturday
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9
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Until
until
1
2
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5
6
7
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9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
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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:
Has the applicant been referred by a medical practioner or other ?
*
Yes
No
If you answered yes, please give details:
Applicants Signature Parent/Guardian Signature (If under 18)
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Submit
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