REFERRAL FORM

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 or guardian: _______________________________________________________

Address: ________________________________________________________________________

Postal Code: ______Home phone: ______________Work phone: ________ Email: __________

Emergency contact name: ______________________Relation: _______________

Emergency phone: ________________________

I will be away on holidays: __________________ Referral by: ______________

Lessons take place:

Spring and Fall 2011:

Cedar Rock in Perth: Monday and Friday: 3:30 - 6:30, Thursday: 9:00 am - Noon

Huntingford Farm, Dwyer Hill Road, Almonte:

Monday and Thursday: 4:40 - 7:30, Tuesday and Wednesday Morning: 8:30am - Noon

Summer 2011:

Cedar Rock Farm, Perth: Monday, Wednesday, Friday morning: 8:30 am - Noon

Huntingford Farm: Monday, Tuesday and Thursday morning: 8:30 - noon

Please circle the area you would like to ride in and state the day and times you are available. ­­­­­­­­­­­­

I would like to ride in : Perth or Almonte (Please circle) Spring Summer Fall

I will be in touch with you to arrange a home visit to meet the new rider, discuss the riding program and to answer any questions you may have. Thank you for your interest.

Susan Cressy

Program Coordinator/Instructor

suecressy@yahoo.ca