Rider Intake Form
Program Enrollment Application must be completed by a parent or legal guardian.
Important Information
At this time there is a wait list of 18 to 24 months. Applications will be processed in the order received. When a class becomes available you will be contacted by a CVTRS representative. Cost of classes is $60/class, billed in term length payments. CVTRS is happy to work with any external funding partner; external funding is the responsibilty of the client.
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Date Submitted
-
Month
-
Day
Year
Participant Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
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Age
Weight
*
(maximum: 150 lbs)
Height
*
(maximum: 5' 10")
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Calculated Age
Age Group
*
Children 12 and under
Youth aged 13-17
Adult aged 18 and above
Parent or Legal Guardian
*
First Name
Last Name
Parent or Legal Guardian (2)
First Name
Last Name
Relationship to Participant
*
Please Select
Parent
Grandparent
Legal Guardian
Myself
?
Phone Number
*
Daytime Phone Number
Format: (000) 000-0000.
Phone Number (2)
Please enter a valid phone number.
Format: (000) 000-0000.
Email
Has the participant ever had a concussion?
*
No
Yes, within the last 6 months
Yes, over 6 months ago
Has the participant ever had a seizure?
*
No
Yes, in the last 12 months
Yes, over 12 months ago
What type of seizure was it?
Please Select
Tonic-clonic (or grand mal)
Clonic seizures
Tonic seizures
Atonic seizures
Myoclonic seizures
Absence (or petit mal)
Focal onset (aware)
Focal onset (impaired awareness)
Secondary generalized
Other (please explain below)
Additional seizure information:
Reason(s) for referral?
*
Anxiety
Depression
Autism
ADHD
OCD
FASD
ODD
PTSD
CP
Developmental Delay
Developmental Disabilities
Other
Additional Information?
Special Needs / Notes?
Extracurricular Activities?
Status
Waitlist
No longer interested
Declined
Unable to Contact
Started Class
T/B/D
Other
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Submit
Thank you for your interest. Your application will be processed in order received. You will be contacted when a class becomes available.
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