Horse Therapy Adult booking form Dec

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Please complete the details on the form and read the following details at the bottom.

Horse Therapy for Adults

'Horse Therapy' is a 3 week programme for adults, to complete to help support with any aniexties and health and wellbeing. Delivered to residents who may need support with mental health or a restart connecting with the world. All sessions will be in Brereton Community Hub, Armitage Rd, WS15 1DF.

You must be able to commit to all 3 week sessions to join the course: *

30th November 10am-1pm

7th Dec 10am - 1pm

14th Dec 10am -1pm

Required

Personal details for the 'Lets Create Wellbeing' Programme

The details below are for the Adult who will be attending the session. Please complete one form per person.

Full Name *

Date of birth *

Please provide details of any disabilities, health or access needs (including allergies) that are relevant to this program.

Do you currently suffer with any mental health issues, anxiety, panic attacks, low self esteem? If yes, please let us know as much detail as you can, including how often and if certain places restrict you (i.e/ Crowded areas, supermarkets, workplaces)

Any medical conditions

Please provide any extra information that will help us make the programme accessible for you

Consents and Emergencies

In the event of an emergency please provide a contact that you would want contacting.

Name of Emergency contact and who they are? *

Emergency Contact Phone Number *

Information for our Funders

These sessions are funded by Brereton Million under our Brereton Can project.

Do you give permission to have your photos/videos taken for our funders advertising purposes of the Brereton Million and Brereton Can Programme. *

Yes

Lets Create Wellbeing Booking Form

Please do let us know if for any reason you cannot make the event after booking your place as we expect to be fully booked.
We will have a reserve list waiting for anyone who drops out to take places.
In the event that you are unwell or come in to contact with anyone who has Covid the same rules will apply.
We will email you all the details to confirm you have a place so please ensure you give us a current email address that you use. If you have any dietary, disabilities or medical needs we will discuss this with you in detail, our program is flexible to all.

Thank you for completing the form if there is anything you think we need to know, please add your comment below and we will get back to you as soon as we can..

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