Samrock Stables Riding Lesson Request
Location: Samrock Stables, Farmingdale NJ | Lesson Duration: Approximately 60 minutes
Rider Information
Rider Name
*
First Name
Last Name
Rider Age
*
Parent/Guardian Name (if rider is under 18)
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email Address
*
example@example.com
Riding Experience
Riding Experience Level
*
First Time Rider
Beginner
Intermediate
Advanced
Height of Rider (inches)
*
Weight of Rider (lbs)
*
Lesson Options
Select Your Lesson Package
*
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Name: A to Z
Name: Z to A
Price: Low to High
Price: High to Low
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( X )
Single Riding Lesson
$90.00
$
90.00
One 60-minute lesson.
4 Lesson Package
$340.00
$
340.00
Four 60-minute lessons (save $20).
8 Lesson Package
$640.00
$
640.00
Eight 60-minute lessons (save $80).
12 Lesson Package
$900.00
$
900.00
Twelve 60-minute lessons (best value).
Total
$0.00
$
0.00
Scheduling Request
Preferred Day
*
Please Select
Thursday
Friday
Saturday
Sunday
Preferred Time
*
Please Select
Morning
Afternoon
Evening
Requested Start Date
*
-
Month
-
Day
Year
Date
Emergency Contact
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
-
Area Code
Phone Number
Liability Acknowledgment
Please acknowledge the following:
*
I understand and accept the risks associated with equine activities.
I agree to complete the Samrock Stables liability waiver before participating.
I acknowledge that helmets are required while riding.
Additional Notes (Anything you would like us to know about the rider)
Request My Riding Lesson
Should be Empty: