Equestrian Therapy Intake
Student Name
*
First Name
Last Name
Parent Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Phone Number
*
Please enter a valid phone number.
Parent Email
*
example@example.com
Student Birthday
*
-
Month
-
Day
Year
Date
Student Diagnosis
*
Other Therapies
*
Student Age
*
Note: For the safety of our staff and students, applicants above the age of 16 will not be added to the wait list.
Student Height
*
Student Weight
*
Note: For the safety of our staff and students, applicants over 100 lbs will not be added to the wait list.
Notes/Comments
Submit
Should be Empty: