D05 Rider Referral

RIDER REFERRAL

Request for Rider to Participate in Dunedin RDA Program
Referral made by:

Details of person making referral
Name of person making referral*

First NameLast Name
Organization/ person /title*
Phone Number*

Phone Number
Email*
example@example.com
Signature of person making referral

Clear
Rider information

This information is required to enable the RDA Group to consider whether they are able to accept the prospective Rider into their RDA programme. All information supplied will be considered confidential, and stored and used in accordance with the Privacy Act 2020.
Rider name *

First NameLast Name
Date of birth*

DayMonthYear
Date
Gender *
Weight*
Height *
Rider address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Phone Number
Reason for referral*
Disability/ Health Condition/ Other information*
What would you like to achievefrom attending RDA? *
Rider/Caregiver to complete

I understand that;
- This information is required to enable the RDA Group to consider suitability to participate in an RDA programme.
- If accepted, further medical or educational information can be supplied for safety and planning purposes.
- Final acceptance will be at the discretion of the RDA Group, after consultation with other relevant people where necessary, and that referral does not guarantee entrance into a riding programme.
- If accepted and understand there is a term fee charged by Dunedin Group Riding for Disabled
Rider/Parent/ Caregiver/Legal Guardian Name and relationship to Rider.*

First NameLast Name
Email address for Parent/Caregiver*
example@example.com
Parent/caregiver signature*

Clear
Should be Empty:

RIDER REFERRAL

Referral made by:

Rider information