New Rider Application

Rider's Name *

First

Last

Age *

Parent/Guardian Name(s): *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Email *

Rider's Full Date of Birth *

Rider's Height *

Rider's Weight *

Rider's Ethnicity

Rider's Disability *

What other therapies does the Rider participate in? (please check all that apply) *

Specific Goals of these Therapies

Specific Goals of Therapeutic Riding *

Psychological Functions *

Aversions *

Transitioning into TROT *

Please give us helpful information about the rider that may help him/her adjust into the program: favorite toys, songs, games, etc.

Is the parent/guardian willing to assist with riding activities as necessary? *