Participant Application Form

The Shane Center for Therapeutic Horsemanship

Participant Application Form
Today’s Date*

MonthDayYear
Date
Participant Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone
Format: (000) 000-0000.
Participant Diagnosis (Type N/A if not applicable) *
Program Applying for:*
Participant Height:*
Participant Weight:*
Participant's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant's Email
example@example.com
Participant's County of Residence*
- EMERGENCY CONTACT:
- 1. Emergency Contact #1's NAME*
- Relationship*
- Phone #*
  Format: (000) 000-0000.
- 2. Emergency Contact #2's NAME*
- Relationship*
- Phone #*
  Format: (000) 000-0000.
- Who is responsible for the participant: (Check ALL THAT APPLY)*
  
  SELF (Over the age of 18 and lives independently)MOTHERFATHERGUARDIANASSISTED LIVINGGROUP HOMEOther
- Name of Company/Group Home, if applicable
- Contact Person Responsible for Participant if not Self:
  
  First NameLast Name
- Address of Contact Person if different than above:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Name
  
  First NameLast Name
- Phone of Contact Person
  Format: (000) 000-0000.
- Email of Contact Person:
  example@example.com
- Please tell us why you are interested in participating at The Shane Center and provide details of any previous equine experiences you have had.*
- Name of Form Filler:*
- Signature of Form Filler*
- The Shane Center for Therapeutic Horsemanship, Inc.
  
  7908 Myers Road Centerburg, OH 43011-9446
  
  Phone: 740-625-9324
  
  www.ShaneCenter.org
  
  Info@ShaneCenter.org
- Should be Empty:

The Shane Center for Therapeutic Horsemanship

EMERGENCY CONTACT: