Participant Application Form

Open this section to fill out the Contact Person who is responsible for the Participant.
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
Email of Contact Person:
example@example.com

Open this section to help us learn more about the Participant and sign application.
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*

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The Shane Center for Therapeutic Horsemanship, Inc.

7908 Myers Road Centerburg, OH 43011-9446

Phone: 740-625-9324

www.ShaneCenter.org

Info@ShaneCenter.org
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The Shane Center for Therapeutic Horsemanship