New Rider Form
Thank you for your interest in Divine Please fill out the form below,
Contact Information
Name of Parent to contact:
Client's Name
*
First Name
Last Name
Billing Address
*
Street Address
Street Address Line 2
City
State
Zip Code
County You Reside In
Grayson
Fannin
Collin
Cooke
Byrant OK
Home Phone Number
*
-
Area Code
Phone Number
Mobile Phone Number
-
Area Code
Phone Number
E-mail
*
Is the participant under the age of 18?
Yes
No
Prefered Method of Contact
Home
Mobile
E-mail
Client's Information
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Height
*
Weight
*
Primary Disability
Secondary Disability
How did you hear about us? example: TCC- CASA- Probation - Other
Day your requesting
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Monday Tuesday Wednesday Thursday or Friday Times your interested in depending on Instructor availability
9:00 - 10:00
10:15 - 11:15
11:30 - 12:30
1:00 - 2:00
2:30 - 3:30
4:00 - 5:00
5:15 - 6:15 Veterans only on Friday nights
6:30 - 7:30
Other
Saturday's Times your interested in depending on Instructor availability
9:00 - 10:00
10:15 - 11:15
11:30 - 12:30
1:00 - 2:00
What Program are you Interested in
Equine Riding Services
Equine Facilitated Psychotherapy
Veteran Program
Thank you, someone from Divine will be contacting in a few days. Please keep an eye out your cookies for emails from us. Press here to send
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