Client Intake Form

Leg Up Equine Client Intake Form

Instructions. Please fill out this form as completely as possible. If a question does not apply to you, please write "N/A" rather than leaving the answer blank. If you are under 18 years of age, please have your parent or guardian sign this form.

Name

First nameLast name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Main phone:

Area CodePhone Number

Mailing address if different than above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email address

example@example.com

Alternate phone:

Area CodePhone Number

Fax number

Are you under 18? (check one):

If "Yes," please answer the following questions: Please list contact information for the parent(s) or guardian(s) with whom you live:

Parent/Guardian Name

First nameLast name

Parent/Guardian Street address

Parent/Guardian City

Parent/Guardian State

Parent/Guardian Zip

Parent/Guardian Mailing address if different than above

Parent/Guardian Email address

example@example.com

Parent/Guardian preferred phone:

Area CodePhone Number

Parent/Guardian Alternate phone number

Who will be primarily responsible for driving you to your lessons? (please specify)

First NameLast Name

Driver Relationship to student:

2. Special Considerations. Do you have any physical limitations or other considerations that may affect your ability to ride and/or handle horses, such as back pain or fear issues? (check one)

If "Yes," please describe the limitations and considerations:

Please help us understand how to best support your individuality.

Is your physician aware that you plan to ride or participate in horse-related activities? (check one)

Has your physician given you any special instructions? (check one)

If so please specify

3.Riding History.

3.1. Riding Experience. How many years have you been riding regularly (i.e., once a week or more)?(check one)

3.2. Areas of Experience. In which equestrian discipline(s) do you have experience? (please specify) Examples might include dressage, Western pleasure, trail riding.

3.3.1. Current Experience. Do you currently compete, or have you competed in the past year? (choose one)

If "Yes", please describe the type of competition(s) and the results you achieved.

3.3. Past Experience. Do you currently compete, or have you competed in the past year? (check one)

If Yes please describe the type of competitions and the results you achieved

4. Horse Ownership. Do you currently own a horse? (check one)

Do you currently lease a horse? (check one)

Have you owned a horse in the past? (check one)

If you currently own and/or lease horses, how many horses do you own or lease? (check one)

How many years have you owned or leased horses? (check one)

What breed(s) are the horse(s) that you own and/or lease? (please specify):

5. Professional Training and Instruction. Have you ever received professional training or instruction? (check one)

If "Yes," for each trainer or instructor you have worked with previously, please complete the following information. Please add additional sheets if necessary.

Worked with the following trainer or instructor from:

Date

through:

Date

Trainer Name

First nameLast name

Name of business or facility

Trainer Street address

Trainer City

Trainer State

Trainer Zip

Trainer phone:

Area CodePhone Number

Trainer Website

Trainer Email address

example@example.com

Went to this trainer or instructor for assistance with: (please specify)

Reason(s) for leaving this trainer or instructor: (please specify)

Were you satisfied with the results you obtained from this trainer or instuctor? (check one)

If "No", please specify why not:

Can we contact this trainer or instructor for more information about you and/or your horse(s)? (check one)

6.Client's Goals. Please help us understand your goals. (Check as applicable) Use "Other" for Compete Successfully in ... or Help with a specific issue goals.

On what day(s) of the week would you prefer to schedule your lessons? (check as applicable)

What time of day works for you?

What type(s) of lessons do you prefer? (check as applicable)8.Other. Is there any other information that would help us understand your needs?

Will you be bringing your own horse for lessons? (check one)

If needing a lesson horse please provide height and weight of rider to ensure horses are properly matched.

Rider hiight and weight

Other preferences (please specify):

8. Other. Is there any other information that would help us understand your needs?

Client

Signature

Name printed

Title

Date

Client's Parent or Guardian Signature*

Name

First NameLast Name

Title:

Date