2019 INTENT TO PARTICIPATE APPLICATION FORM

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

After you have completed and submitted this application form, we will be in contact with you in order to arrange an in-person visit to meet the new applicant, to discuss their participation in the riding program and to answer any questions you may have. If you are a returning rider, we will be in contact to confirm if we have a lesson spot available for you and if any of your forms on file require updating. Applications are accepted as of January 1, 2019 and are reviewed with lesson spots allocated on a first come, first serve basis. Thank you for your interest in our program!
Date:
Name of Rider:
Date of Birth:
Height:
Weight:
Disability & description of how they are affected:
Reason for interest in this program:
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 Fox Hollow Farm in Almonte, ON
Referral by:
Session preference:		Spring Summer Fall
First choice for lesson day & time:		Monday evenings (independent rider requiring minimal assistance) Tuesday mornings Wednesday evenings Thursday mornings
The best day and time for lessons: