GallopNYC Prospective Therapeutic Rider Form

GallopNYC Prospective Therapeutic Rider Form
Please use this form to express interest in the Therapeutic Riding program at GallopNYC.

If you are interested in another program, please visit our Programs page for more information.

If you are unsure, or would like more information, please contact us at info@gallopnyc.org
Parent Information (or Rider Information if the rider is an adult)
Title
Name

First NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone (mobile preferred)
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Rider Information
Rider's First Name
Rider's Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Weight
Height
Rider Primary Diagnosis
Rider Secondary Diagnosis (if applicable)
How did you hear about Gallop NYC?
Type of Lead
Mobility Status
US Armed Forces Veteran
Veteran Military Branch
Contraindication
Rider Avail Location
Rider Avail Day + Time
Are you interested in applying for a Scholarship?
Do you participate in Self-Direction?
Ethnic Backgound
Please list any additional riders
Any other comments, questions, or concerns

0/32000
Program Interest
Please verify that you are human
Should be Empty: