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Prospective Client Registration Form

Client First Name
Client Last Name
Parent/Guardian Name
Caretaker Name (if accompanying to lessons)
Name of Contact Person
(if different from parent/guardian)
Referred By
Parent/Guardian Address if different from above
Best Phone Number
Phone Type
Client's Age
Client's Height
Client's Weight
Health History
Ambulatory: Yes    No
Verbal: Yes    No
Has client participated in Adaptive Riding or Hippotherapy Previously: Yes    No
Do you have specific goals for adaptive riding lessons:
Client of Developmental Pathways?: Yes    No
Please select days and times the client is available: Monday Mornings
Monday Afternoons
Monday Evenings
Tuesday Mornings
Tuesday Afternoon
Tuesday Evening
Wednesday Mornings
Wednesday Afternoons
Wednesday Evenings
Thursday Mornings
Thursday Afternoon
Thursday Evening
Friday Mornings
Friday Afternoons
Friday Evenings
Saturday Mornings
Saturday Afternoon
Saturday Evening