GallopNYC Prospective Rider Form

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Please use this form to express interest in the therapeutic riding program at GallopNYC.

If you are interested in another program, please follow this link for more information:


If you are unsure, or would like more information, please contact us or call 646-233-4507
Parent Information (or Rider Information if the rider is an adult)

Rider Information

Please enter date as MM/DD/YYYY

EX: verbal/nonverbal, uncontrolled seizures, social, etc.

Ambulatory? Assistive Device?

First + Last Name

Please add any information you would like to share with us