Horse Sense & Healing Application

1

Are you applying for yourself or someone else?* This field is required.

MyselfSomeone else

2

Your Name

First Name

Last Name

3

Relationship to Applicant

4

Applicant Name* This field is required.

First Name

Last Name

5

Preferred Date(s) to Attend* This field is required.

April 11 - 13, 2025

June 27 - 29, 2025

August 15 - 17, 2025

November 22 - 24, 2025

No preference

6

Email* This field is required.

7

Phone Number* This field is required.

Please enter a valid phone number.

8

City and State of Current Residence* This field is required.

City

State

Zip Code

Country

10

Gender* This field is required.For housing purposes

Female

Male

Non-Binary

12

Have you been diagnosed with PTSD?* This field is required.A formal diagnosis is not a requirement for successful application. This data is collected to use anonymously for grant reporting.

Yes, I have been diagnosed with service-connected PTSD by the VA

Yes, I have been diagnosed with PTSD by the VA, but it is not service-connected

Yes, I have been diagnosed by a private physician

No, I do not have a formal diagnosis

I'd prefer not to answer

Other

13

If you answered other on the PTSD question, please specify.

14

Is there any additional information you'd like to know?

15