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Purple Pony Therapeutic Horsemanship

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Rider Application Form

Session Cost:

$387.00 for 9 week session

*Payment is due by the first lesson unless Self Direction agency requests otherwise*

First name*

Last name*

Birthday

Month

Day

Year

Parent/ Guardian Name*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Home Phone*

Cell Phone

Email*

MAILING ADDRESS

P.O. Box 148

Bergen, NY 14416

PROGRAM ADDRESS

8321 Lake Street Road

LeRoy, NY 14482

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