Praying Hands Ranch Application

FORMS

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
Address
City
County
State
Zip
Parent/Guardian Address if different from above
Email
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