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Adventures Lesson Participant Application
Thank you for your interest in our therapeutic riding program. Upon completion of this application you will be contacted to schedule a tour of our program. The tour will include interactions with our horses, an assessment of the participant's mounted abilities (using our Equicizer) and a discussion of goals for the session.
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* Indicates required question
Email
*
Your email
What is today's date?
*
MM
/
DD
/
YYYY
What is the participant's name?
*
Your answer
What is the participant's address?
*
Your answer
What lesson type are you interested in?
*
Private Therapeutic Lessons (tailored to your needs)
Small Group Therapeutic Lessons - All Horses (using all aspects of our equine environment)
Small Group Therapeutic Lessons - All Access (using all aspects of our Adventures environment)
Horticulture Lessons
Does the participant have a clinical diagnosis?
*
Yes
No
Other:
If yes, please specify
Your answer
What may be the rider's primary goals? (Check all that apply)
*
Focus (Following Directions, Attention to Task)
Self Awareness (Self Control, Emotional Regulation, Articulating Emotions, Safety Awareness)
Confidence (Self Esteem, Assertiveness)
Social Interaction (Acknowledging Others, Reciprocal Conversation, Positive Communication, Reading Body Language, Taking Responsibility)
Cognitive Growth (Horsemanship Skills, Sequencing, Problem Solving)
Body Awareness (Balance, Strength, Body in Space, Recognizing internal sensations)
Required
Is the participant fully ambulatory?
*
Yes
No
Participant Birth Date
*
MM
/
DD
/
YYYY
Participant Height
*
Your answer
Participant Weight - weight limit is 180 lbs
*
under 80 lbs
80-120 lbs
120-180 lbs
Availability for Lessons
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Required
Has the participant ridden before?
*
Yes
No
Parent/Guardian Name
*
Your answer
Parent Guardian Email
*
Your answer
Parent/Guardian Phone Number
*
Your answer
How did you hear about us?
*
Facebook
Website
Friend
Flyer
Other:
Required
A copy of your responses will be emailed to the address you provided.
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