CKRH Instructor in Training Application

Page 1

CKRH Mission Statement

Central Kentucky Riding for Hope is dedicated to enriching the community by improving the quality of life and the health of children and adults with special physical, cognitive, emotional and social needs through therapeutic activities with the horse.

General Information

Prefix

First Name

Last Name

Birthdate

mm/dd/year

Employer or School Name

Highest Level of Education

Address Information

Mailing Number/Name

Please spell out all parts of the address including the Street, Road, etc.

Mailing City

Mailing State

Mailing Postal Code

Contact Information

Email

Phone

Preferred Method of Communication

PhoneEmailEither one

Page 3

Short Answer

Why are you interested in becoming a Therapeutic Riding Instructor?

Page 4

Intern's Authorization for Emergency Medical Treatment

First Name

Last Name

CKRH asks for medical information to ensure the safety of all of our interns. It is in your best interest to complete this section. However, if you do not fill out this section, CKRH will use their standard safety measures in the case of an emergency.

Medical Information

Hospital Preference

Physician's Name

Physician's Phone Number

Health Insurance Company

Policy #

Emergency Information

Emergency Contact

Emergency Contact Phone

Able to walk for 45 minutes

YesNo

Health Issues or Physical Limitations

YesNo

Do you have any medical conditions that would prevent you from participating in lessons? (Walk/trot)

Current Medications

Information for Emergency Responders/Please List Any Alergies