Horses For Hope - Therapeutic Riding Request Form

1 Step 1
Rider Information
2 Step 2
Contact Information
3 Step 3
Rider Availability
4 Step 3
Confirmation

Please tell us a bit about the rider:

NOTE: Horses for Hope considers the safety of our riders and our horses as our top priority. We reserve the right to limit the age and weight of our riders. Should such limitations apply, we will try to provide an alternate solution.

Name:


(First)	(Middle)	(Last)

Rider Date of Birth:

Height (in):

Weight (lbs):

Diagnosis:

High Functioning: Yes No

Parent or Guardian if under age 18 or if rider is in full-time care:

Contact #1:

Name:

EMAIL address:

Contact Number: ( ) -
Allow text messages?

Carrier

Contact #2:

Name:

EMAIL address:

Contact Number: ( ) -
Allow text messages?

Carrier

Rider Availability:

When are you available to ride? Check all that apply:

Select	Description

Which program would you prefer? Go to our web site for more information about each of these programs.

Select	Description

Please Confirm Your Registration Info:

Rider

Name:		DOB:
Height (in):		Weight (lbs):
Diagnosis:		High-functioning?

Contacts

Contact #1 Name:
EMAIL:
Phone:
Text Msg Carrier:

Rider Availability

Selected Availability:
Selected Program:

By clicking the REGISTER button, I acknowledge that I am requesting placement on a waiting list for the selected therapeutic riding program but that some prospective participants may not qualify to ride due to certain contraindications that may exist.