Prospective Client Registration Request

Please enter information and someone will contact you.

Please provide the following contact information:

Client First Name
Client Last Name
Parent/Guardian Names
Referred by
Street Address
City
State/Province
Zip/Postal Code
Name of Contact Person & Work No.
Home Phone
FAX
E-mail
Age
Weight
Height
Student Ridden Before	If so, where
		How Long
Fear of horses or animals
Allergies	If so, to what
Special Needs (Please give as much information as possible)
What are the goals that the Parents, Adult students or Therapist are currently working on. (Please give as much information as possible)
Please list dates and times available (Please give three options)