Application and Health History

Parent or Guardian Information

First name*

Last name*

Address*

Phone Number with Area Code*

Email*

Participant Information

First name*

Last name*

Address (if different from above)

Primary Phone Number (if different from above)

Birthday*

Month

Day

Year

Height*

Weight (in lbs)*

Gender*

Health History (not required for current students)

Diagnosis

Date of Onset

Please indicate current or past special needs in the following areas by checking any boxes that apply. For each box checked, please add a comment in the field below.

Vision

Hearing

Sensation

Communication

Heart

Breathing

Digestion

Elimination

Circulation

Emotional/Mental Health

Behavioral

Pain

Bone/Joint

Muscular

Thinking/Cognitive

Allergies

Seizures

Comments

Medications (include prescriptions, over-the-counter; name, dose frequency)

Describe the rider's abilities/difficulties in the following areas (include assistance required or equipment needed).

PHYSICAL FUNCTION (i.e. Mobility skills such as transfers, walking, wheelchair use, driving/bus riding)

PSYCHO/SOCIAL FUNCTION (i.e. Work/school including grade competed. leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc.)

GOALS (i.e. Why are you applying for participation? What would you like to accomplish?)

Do you have any conditions which might be affected by the weather (heat, cold), the environment (insect allergies, asthma, dirt), or animals (allergies)?

Any additional comments

PLEASE READ: Clicking submit does not finalize registration in our program. You will receive a follow-up email or call in the next few days, to determine if our program is a good fit, and potentially set up an evaluation.