Participant General Information Form:
Participant Full Name
*
First Name
Last Name
Program interested in
*
Please Select
Therapeutic Riding/ Driving
Riding School
Adult introduction to horses and riding
Gender
Please Select
Male
Female
Do not wish to share
Date of Birth
-
Day
-
Month
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Information
This is the individual that will be contacted for all correspondence for participant
Main Contact
*
First Name
Last Name
Main contact's relation to participant
*
Main Contact phone number
*
E-mail
*
example@example.com
Billing information
All invoices will be sent by email. Please indicate the email that invoice should be sent to.
Billing email
*
example@example.com
Emergency Contacts
Please private 2 individuals that can be contacted in event of emergency
Name of Emergency Contact #1
*
Relation to participant
Phone Number of Emergency Contact #1
*
Please enter a valid phone number.
Name of Emergency Contact #2
Relation to participant
Phone Number of Emergency Contact #2
Please enter a valid phone number.
Medical Form
Requirement of Medical Form: I understand that all therapeutic programs (Therapeutic Riding and Therapeutic Horse Driving) require a medical filled out by physician before registering for the program. The medical form is available on the website in printable format only.
Upload medical form:
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Medical repeat
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