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:

LINK TO COME HERE

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)

Title

First Name

Last Name

Address:

Street

City

State

Zip Code

Phone

Are you interested in (check all that apply)

Therapeutic Riding (for you or your child)

Company

Are you signing up for therapeutic riding for yourself or for someone else?

Rider Information

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Please enter date as MM/DD/YYYY

Weight (lb)

Primary Diagnosis

Secondary Diagnosis (if applicable)

Any Additional Information Relevant to Diagnosis

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

Mobility Status

Ambulatory? Assistive Device?

Contraindications (Check all that apply)

Hip Subluxation/Dislocation Osteogenesis Imperfecta Scoliosis > 30Atlantoaxial Dislocation ConditionOsteoporosis Total Hip Arthroplasty Hydrocephalus/Shunt Spinal FusionSeizure Disorders Spinal Instability Spinal Cord Injury Above T12

Preferred Location (Check all that apply)

Brooklyn - Bowling Green at Prospect ParkQueens - Forest HillsBronx - Bronx Equestrian Center (Pelham Bay Park)Queens - Sunrise Stables (Lindenwood)

Preferred Day/Time (Check all that apply)

Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PMThursday AMThursday PMFriday AMFriday PMSaturday AMSaturday PMSunday AMSunday PM

Please List any Additional Riders

First + Last Name

Any other Comments, Questions, or Concerns

Please add any information you would like to share with us

Are you Interested in Applying for a Scholarship

YesNo

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Contact Information