Returning Rider Application | Purple Pony Therapeutic Horsemanship

Application Date

Participant Information

First name

Last name

Gender

Height

Weight

Date of Birth

Age

Disability

Parent Full Name

Address

City

State

Zip Code

Riders Current School

Grade

Below are several options for enrollment in three class options. Please use the the first row of drop down choices to select your first and second choice for Regular Therapeutic lesson times. If you are riding in our Independent Riding or Showmanship(Ground) Classes, please select the correct class from the second row of drop down options. Every effort will be made to place riders into their 1st choice, but flexibility is greatly appreciated as we match riders with our horses, volunteer availability and class dynamics.

First Choice for Regular Lesson Program

Second Choice for Regular Lesson Program

First Choice for Independent Riding Class (Invitation Only)

Showmanship Ground Class

Parent/Guardian that will be attending lessons with rider?

Preferred Contact Method

Phone

Choose one

Email (for primarycaregiver)

Emergency Contact Info

Physician's Name

Phone

Health Ins Co

Policy #

Known Allergies

MEDICATIONS we should be aware of:

Describe any CHANGES in rider's abilities or difficulties in PHYSICAL FUNCTON

Describe any CHANGES in rider's abilities or difficulties in PHYSCO/SOCIAL FUNCTON

GOALS: What would you like to accomplish

PHOTO RELEASE

I DO

I DO NOT

consent & authorize the use & reproduction by Purple Pony Therapeutic Horsemanship, Inc. of any and all photograaphs and anyother audio/visual materials taen of me for prootional material, educational activities, exhibitions or for any other use for the benfit of the program.

Consent Signature

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