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):*

YesNo
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)*

YesNo
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)*

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

YesNo
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)*

More than 10 years6-10 years3-5 years1-2 yearsLess than 1 yearHave not been riding regularly
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)*

YesNo
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)*

YesNo
If Yes please describe the type of competitions and the results you achieved
4. Horse Ownership. Do you currently own a horse? (check one)*

YesNo
Do you currently lease a horse? (check one)*

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

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

123-5More than 5
How many years have you owned or leased horses? (check one)

Less than 1 yr.2-5 years5-10 yearsMore than 10 years
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)*

YesNo
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:

MonthDayYear
Date
through:

MonthDayYear
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)

YesNo
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)

YesNo
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.*

Feel more confidentImprove my skills and gain more experienceHave fun and make new friendsTry something newOther
On what day(s) of the week would you prefer to schedule your lessons? (check as applicable)*

MondayTuesdayWednesdayThursdayFriday
What time of day works for you?*

7 am - 11 am11 am - 3 pm3 pm - 6 pm6 pm - 9 pm
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?

Group lessonsSemi-private lessonsPrivate lessons
Will you be bringing your own horse for lessons? (check one)*

Yes I will use my own horseLesson horse neededMy horse/lesson horse depending on lesson
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

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Name printed
Title
Date

MonthDayYear
Date
Client's Parent or Guardian Signature*

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Name

First NameLast Name
Title:
Date

MonthDayYear
Date
Should be Empty: