Wait List Application

Participant Full Name

First NameLast Name

Date of Birth

Date

Age

Gender

Height

Weight

Participant Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Home Phone

Please enter a valid phone number.Format: (000) 000-0000.

Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Primary Contact Full Name

First NameLast Name

Primary Contact Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Primary Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Primary Contact Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Guardian Full Name (if applicable)

First NameLast Name

Guardian Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Guardian Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Participant lives with

Group home cancellation contact name and number

Is the group home contact the primary contact?

How did you hear about the program?

Referral source

Referral source phone

Please enter a valid phone number.Format: (000) 000-0000.

School

Enter N/A if participant is not in school

Is the participant homeschooled?

Lesson availability

Primary diagnosis

Primary diagnosis date of onset

Date

Secondary diagnosis

Enter N/A if no Second diagnosis

Secondary diagnosis date of onset

Enter birthdate if no Second diagnosis

Vision needs

Vision comments

Hearing needs

Hearing comments

Sensations needs

Sensations comments

Communication needs

Communication comments

Heart needs

Heart comments

Breathing needs

Breathing comments

Digestion needs

Digestion comments

Elimination needs

Elimination comments

Circulation needs

Circulation comments

Emotional/Mental Health needs

Emotional/Mental Health comments

Behavioral needs

Behavioral comments

Pain needs

Pain comments

Bone/Joint needs

Bone/Joint comments

Muscular needs

Muscular comments

Thinking/Cognition needs

Thinking/Cognition comments

Allergies

Allergies comments

Other special needs

Other special needs comments

Atlantoaxial dens interval X-ray date (Required if Downs Syndrome is diagnosed)

Date

Atlantoaxial dens interval X-ray result (Required if Downs Sundrome is diagnosed)

Date of last neurological exam (Required if Downs Syndrome is diagnosed

Date

Symptoms of atlantoaxial instability? (Required if Downs Syndrome is diagnosed)

Physical Function, Abilities, Difficulties, Assistance, and Equipment. Please give as much detail as possible.

Psychosocial Function, Interests, Relationships, Support Systems, Fears, and Concerns. Please give as much detail as possible.

Goals and Reason for Applying. Please give as much detail as possible.

BILLING POLICY & RATES

*Rates are subject to change. 6-week session is $480, due at the first lesson of each session (effective 05/1/2026)

($125/lesson if paid weekly) Application Fee: $50 (one-time)

Session length: Sessions will run 6 weeks on and 2 weeks off throughout the year. Holiday weekends will be accommodated in the schedule.

Attendance: Our staff, volunteers, and horses are waiting for you, and your spot is reserved. A 24-hour notice is required if a lesson needs to be canceled. If a lesson is cancelled at least 24 hours in advance, you will be offered ONE make-up lesson per 6-week session. This make-up will be scheduled within our regular scheduled lessons. If make-up is not available within the 6-week period, then make-up can be rolled to the next session but will be forfeited if not made up within 60 days. No Show/No call/Late notice absences will not be eligible for make-up or a refund. After 3 absences, eligibility will be reviewed by the Loving Thunder staff.

Payments: Lessons are to be paid in full according to this rate sheet on the 1st day of the 6-week session. We can provide an invoice in advance if you need to submit for payment. The payment box is mounted on the chain link fence at the entrance to the horse area. A late fee of $50 will be applied if the invoice is not paid in full within 30 days. Payment can be made by check, cash, or credit card. Checks presented with insufficient funds will incur a $35 NSF fee.

Mi Via Clients: Parent/Guardian is responsible for full payment if Mi Via payment is declined due to no fault of LTTR. It is the responsibility of the guardian to verify Mi Via eligibility, invoice submission, and payment. Invoice and VPR will be sent to parent/guardian at the end of each month for immediate submission. Participants with Mi Via funding will be billed at the end of each month.

LTTR cancellation: Cancellations due to weather or other circumstances by LTTR will be credited accordingly.

Re-Enrollment for the Next Session: You will be AUTOMATICALLY ENROLLED IN THE NEXT SESSION, at your same time slot, UNLESS WE HAVE BEEN NOTIFIED OF INTENT TO WITHDRAW BY THE LAST DAY OF THE CURRENT SESSION.

Please notify us no later than the last lesson of the session if you do not plan on returning for the next session, So we can allow another rider to join us.

I have read the current Rate sheet and Safety Guidelines and agree to both policies of Loving Thunder Therapeutic Riding, Inc.

Billing Preference

Bill at beginning of each Six-week session

$480 per session

$480.00

Bill monthly

$240 partial session payment

$240.00

Total

Acknowledgment of Rate Sheet

Participant/Parent/Legal Guardian Signature

Date

Wait List Application

Participant Information

Contacts

Living Situation, Referral, and School

Diagnoses and Health Needs

Function and Application

Billing and Acknowledgment

Billing Preference