Horses Helping Humans REFER/ENROLL FORM
232 Hopkinson Road, Darling Downs 6122 Mob: 0409 993 097
Participant details:
Required for all referrals.
Participant Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
Suburb
State / Province
Post Code
Participant E-mail
example@example.com
Participant Phone Number
Mobile number preferred
Gender Identity:
*
Female
Male
Other
Participants Age:
*
7 - 12 years
13-17 years
18-24 Years
Other
Does the Participant identify as:
*
Australian
Aboriginal / Torre's Strait Islander
Migrant
Refugee
Other
Does the participant have prior experience with horses or ponies?
Yes
No
Not known
If yes, provide brief details?
How many months, or years, indicate level achieved.
Does the participant have underlying health, social or behavioural issues?
*
If no, please enter none..
Does the participant have any known allergies?
*
If no, please enter none.
Reason for referral
*
Provide a brief reason for making the referral.
Emergency Contact details: (required for all participants)
*
Mobile numbers preferred
Preferred Activity schedule:
School Holidays Term 2 - 7-12 July
School Holidays Term 2 - 14-19 July
T3 Monday's 11am -1pm 21 Jul - 4 Aug
T3 Monday's 11am-1pm 11 Aug - 25 Aug
T3 Monday's 11am-1pm 1 Sept - 15 Sept
T3 Tuesday's 3pm-5pm 22 Jul - 5 Aug
T3 Tuesday's 3pm-5pm 12 Aug - 26 Aug
School Holidays Term 3 - 29 Sept -4 Oct
School Holidays Term 3 6 Oct - 11 Oct
Other
Who is making this referral?
Parent, or Caregiver
Teacher, School / College
Youth, or Support Worker
Health Professional
Other
Referral by Parent or Caregiver:
Required for all participants under 18 years.
Parent, Caregiver - Full Name (if under 18 years)
First Name
Last Name
Parent, Caregiver - E-mail (if under 18 years)
example@example.com
Parent, Caregiver - Phone Number (if under 18 years)
Mobile numbers preferred
Will you provide transport to the program venue?
Yes
No
Other
If no, how will the Participant get to the venue?
232 Hopkinson Road, Darling Downs 6122
Will you stay at the venue for the duration of the activity session?
Yes
No
Other
Referral by an organisation:
Required if referral made by a LGA - Govt.Dept - School/College or other Service Provide.
Name of Referring Organisation?
Location or Branch of Referring body?
Phone Number of Person Referring?
Mobile numbers preferred
Will you provide transport to the program venue?
Yes
No
Other
If no, how will the Participant get to the venue?
232 Hopkinson Road, Darling Downs 6122
Will staff stay at the venue for the duration of the activity session?
Yes
No
Other
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