Student Questionnaire Form

Student Questionnaire
Personal Information:
Student's Name*
Parent's Name (if minor)
Age
School
Grade
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent's Phone Number (if Minor)*

Area CodePhone Number
Student's Phone Number

Area CodePhone Number
E-mail*
Questions and Details:
Commitment level?

Positive I want to start lessons in SeptemberReally interested but still trying to see if it fits our budgetReally interested but still trying to see if it fits our time commentmentsStill just thinking about it
What time of riding are you interested in?

Beginner EnglishJumping/EventingDressageBeginner WesternRopingRanch Riding/Trail
What kind of lesson would you like?

Private (1 Student $75)Semi-Private (2 Students $55)Group (4 Students $45)
I want to use a lesson horse?

No, I have my own horseNo, I have my own horse I want to haul inYes
Riding level?

Only rode in one week of Camp this summerRode in two or more camps this summerTake regular lessons feel confident at the Walk and TrotTake regular lessons feel confident at the Walk, Trot and CanterTake regular lessons feel confident at the Walk, Trot and Canter and Small JumpsOther
What days are you available for Riding Lessons?

Lessons will be held once a week. Check the box to all the times on the days you are available to ride. I would like more options than one so I can make groups that fit together.
Monday

9:00 am10:30 am2:30 pm5:00 pm6:00 pm7:00 PM
Tuesday

9:00 am10:30 am2:30 pm5:00 pm6:00 pm7:00 PM
Wednesday

9:00 am10:30 am2:30 pm5:00 pm6:00 pm7:00 PM
Thursday

9:00 am10:30 am2:30 pm5:00 pm6:00 pm7:00 PM
Friday

9:00 am10:30 am2:30 pm5:00 pm6:00 pm7:00 PM
I would like to join the Pony Club

YesNoWould like more information
I am interested in the Off campus PE and lettering program

YesNoWould like more information
Would you like to volunteer at the barn?

No, I don't have timeYes, Once a weekYes, Twice a MonthYes, Once a Month
My favorite way to help is

Feeding HorsesCleaning StallsCleaning TackWork Days
What are your Riding Goals?
Should be Empty: