SESSION REGISTRATION
Spring / Summer / Fall / Winter
Participant Name
First Name
Last Name
Age
Birthdate
-
Month
-
Day
Year
Date
Parent or CareGiver Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State Abbrev i.e. IA
Postal / Zip Code
Participant Diagnosis (Brief)
Equine Assisted Services
Therapeutic Horsemanship/Adaptive Riding
Equine Assisted Learning (Unmounted/Ground Work)
Equine Assisted Therapy (Occupational Therapy)
Participant Riding Level
Level 1 New
Level 2 Emerging
Level 3 Walk and Trot
Level 4 Canter
Please Select ALL Times That Could Work for Participant to Come Once Weekly
Tuesday
Wednesday
Thursday
12:30-1:30 PM
2:00-3:00 PM
3:30-4:30 PM
5:00-6:00PM
6:30-7:30PM
Please Write PREFERRED Day/Time to Come Once Weekly or Once BiWeekly (Riders will be grouped by age and similar skill development or 1:1 therapy. )
Please Share Participant GOALS :: Hope to Improve/Experience in 6-week Session
I understand that the $65/hour payment for entire session (i.e.$390 for six weeks) is expected the First Week of Session. Therapy fees are in addition to the $65/hr and are payable to the therapist. If RoG cancels, a makeup time will be offered. If Participant cancels, no makeup will be offered. Failure to notify RoG in advance of horse prep and volunteer arrival may adversely impact future participation in light of wait list of riders that wish to participate.
*
Parent/Caregiver Signature Required
Annual Registration Fee for Returning Participants - Pay ONCE ANNUALLY - Do not check box on left if you have already paid annual or new participant fee this year.
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Annual Registration Fee
For Returning Participants. Complete Participant Application Forms, Medical and Physican Forms.
$
35.00
Quantity
1
2
3
4
NEW Participant Intake Evaluation (Includes Annual Registration Fee)
For New Participants Only. Complete Participant Application Forms, Medical and Physican Forms.
$
75.00
Quantity
1
2
3
4
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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