New Participant Application
Please complete the form to the best of your ability so that we may find the best fit for the Participant in our program.
Participant's Information:
Please note that if Participant is a minor or dependent, Parent/Guardian contact information will be used for primary contact.
Participant's Name
*
First Name
Last Name
Birth date:
*
/
Month
/
Day
Year
Date
Is the Participant a dependent?
*
Yes
No
Height
e.g. 5' 5"
Weight
in lbs.
Contact Information
Please provide Parent/Guardian contact information is Participant is a dependent.
Parent/Guardian Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Please enter a valid phone number.
Email
example@example.com
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Lesson Information
Please answer the following questions to help us determine the best lesson schedule for the participant.
Which lessons are you applying for? (check one)
*
Therapeutic Riding Lessons
Group Riding Lessons (Western/English)
Please let us know what day and time of day works for you:
*
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Participant's Health History
Please be as detailed as possible to provide Hope Ranch staff with the necessary information about the participant.
Diagnosis:
Posture:
Balance:
Movement/Coordination:
General Attitude & Behavior:
Communication Challenges & Methods (nonverbal, ASL, etc.):
Mobility Challenges & Methods (i.e. balance, walking, wheelchair, walker, etc.):
Cognitive Abilities (age level, attention span, problem solving, etc.):
Please indicate current or past difficulties in the following areas:
Vision
Bone/Joint
Hearing
Heart
Elimination
Behavioral
Sensation
Breathing
Circulation
Pain
Thinking/Cognition
Speech/Communication
Please explain any checked boxes:
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Additional Information
Please answer the following questions so that we best prepare for the participant.
Is there any pertinent medical considerations our staff may need to know about the participant?
What are your goals for applying for participation? What would you like to accomplish?
Riding skills, physical improvement, change in behavior, paying attention, etc.
Submit
Should be Empty: