Therapeutic Horsemanship Interest Form
Client Information
Full Name
Date of Birth
Height
Weight
Parent/Guardian Name:
Phone
Email
Diagnosis
Primary:
Secondary (If applicable):
Seizures:
Yes
No
Type of Seizures:
Which program are you interested in? (Check all that apply)
Therapeutic Riding
Therapeutic Carriage Driving
Equine Assisted Learning
Interactive Vaulting
Additional Information
Is there anything else you would like us to know before we contact you? (optional short answer)
Consent
I understand that submitting this form does not reserve a designation on our schedule.
Once an interest form has been submitted, a copy of the completed form will be emailed to you, and a member of the Equest team will contact you.