4:13 Therapeutic Riding Association Participant Application Form  
Please note: Completion of this application does not ensure acceptance into the program.
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Please Check Session Preference  *
Please Check Lesson Day Preference *
Obbligatorio
Applicant’s Last Name *
First Name *
Date of Birth
 *
GG
/
MM
/
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Age
 *
Gender *
Height in inches *
Weight in pounds 
*please note our weight limit is 170lbs
 *
Address
 *
Phone Number *
Phone Number
*for lesson cancellation or in case of emergency
 *

Email

*all registration and program communications will be sent to this address

 *
Parent(s)/Guardian(s) *
Parent(s)/Guardian(s) Address 
(if different than above)
Parent(s)/Guardian(s) Phone Number 
(if different than above)
Name of Emergency Contact *
Emergency Contact Phone Number *
Relationship to Emergency Contact *
Name of Physician *
Physician Phone Number *
Physician Email 
Primary Diagnosis *
Secondary Diagnosis *
Seizure Activity  *
Fractures within the last 6 months *
Surgeries within the last year *
Please list current medications (name/time/dose/reason.) *
Please list any allergies (medical or environmental.) *
Please describe any difficulties in physical mobility. *
Please describe the applicant’s psychosocial functioning
(work/school, extracurricular activities, hobbies, likes/dislikes, strengths/weaknesses, fears, concerns.)
 *
Please describe any strategies that are effective in supporting the applicant’s physical, mental, behavioral or social-emotional needs.
 *
Please identify any goals or areas of focus
(what would you like to achieve, improve, strengthen.)
 *
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