SCSDR & Dr. Marie Wargo- Equine Assisted Therapy Program

SCSDR & Dr. Marie Wargo- Equine Assisted Therapy Program

Please fill out the form below to register for our specialized therapy course.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Residential Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Medical Conditions/HX*
Please enter all applicable diagnosis
Medications *
Please enter all current medications
Primary Care Physician*
Please enter PCP and Phone Number
Health Insurance Plan*
ID Number*
Subscriber Name *
**If you do NOT have Health Insurance Please Enter Annual Income *
Annual Income for 2024
Emergency Contact Name*
Emergency Contact Phone*
Please enter a valid phone number.
Interested in Additional Services?

Horse GroomingCounseling sessionsFollow-up workshops
Signature to Confirm Registration*

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