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

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: