NEW RIDER APPLICATION FORM FOR 2017 RIDING SEASON

Lanark County Therapeutic Riding Program
30 Bennett Street, Carleton Place, ON K7C 4J9
613-257-7121, x3236
Fax 613-257-2675 www.therapeuticriding.ca

 

 

New Rider Application Form 2017

After you have completed and submitted this application form, I will be in touch with you in order to arrange a home visit to meet the new rider, to discuss their participation in the riding program and to answer any questions you may have. Thank you for your interest.

 

Amy Booth

Program Coordinator

Date:  
Name of Rider:  
Date of Birth:  
Height:  
Weight:  
Disability & description of how they are affected:  
What do you hope to gain from the riding :  
Name of parent/guardian:  
Address: (St., City)  
Postal Code:  
Home Phone:  
Work Phone:  
Email:  
Emergency contact name:  
Relation:  
Emergency phone:  
 

Lessons take Place:

Spring (May-June), Summer (July-August) and Fall (September-October) at two locations: 

Smiths Falls Location: Corner Stone Stables, Port Elmsley
Beckwith Location: Ashland Farm

Referral by:  
I would like to ride in:    Smiths Falls       Beckwith   
I would like to ride in:      Spring       Summer       Fall   
The best day and time for lessons: