NEW RIDER APPLICATION FORM FOR 2018 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

After you have completed and submitted this application form, we will be in touch 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. Thank you for your interest.
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: