ManeGait Therapeutic Horsemanship
Rider Application
Participant Information
First Name
Last Name
Preferred Name (if different from First Name)
Street Address
City
State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
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District Of Columbia
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Maine
Maryland
Massachusetts
Michigan
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New York
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Ohio
Oklahoma
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Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip
Mobile Phone Number
Home Phone Number
Work Phone Number
Email Address
Preferred Contact Method
Mobile Phone
Home Phone
Work Phone
E-mail
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Is the participant under 18 years of age or do they have a legal guardian?
Yes
No
Is the participant a veteran?
Yes
No
Military Branch
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Army
Aiforce
Navy
Marines
Coast Guard
DD Form 214
Discharge Type
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Honorable
Less than honorable
Dishonorable
Is the participant a first responder?
Yes
No
Participant School / Employer
Parent / Guardian Information
Parent / Guardian First Name
Parent / Guardian Last Name
Parent / Guardian Mobile Phone Number
Parent / Guardian Email
Relationship to Participant
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Legal Guardian
Caregiver
Parent
Emergency Contact
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Emergency Contact Information
Emergency Contact
First Name
Emergency Contact
Last Name
Emergency Contact
Mobile Phone Number
Emergency Contact Email
Medical Information
Participant Date of Birth
Participant Gender
Male
Female
Participant Height
Participant Weight
Primary Diagnosis
Please select...
Agenesis of the Corpus Collosum
Angelmans Syndrome
Apraxia
Asperger Syndrome
Attention Deficit Disorder (ADD)
Attention Deficit Hyperactivity Disorder (ADHD)
Auditory Processing Disorder
Autism
Brain Injuries
Cardiovascular
Cerebral Palsy
Chromosomal Disorder
Cognitive Delay
Communication Disorder
Congenital Anomaly
Cystic Fibrosis
Deafness
Developmental Delay
Down Syndrome
Dyslexia
Encephalopathy
Epilepsy
Failure to Thrive
Fetal Alcohol Syndrome
Gulf War Syndrome
Hearing Impairment
Hydrocephalus
Hypomylenation
Hypotonia
Intellectual Disability
Learning Disabilities
Medulloblastoma
Metatropic Dysplasia
Microcephaly
Mitochondrial Disease
Multiple Sclerosis
Muscular Dystrophy
Obsessive - Compulsive Disorder
Oppositional Defiant Disorder
Other
Parkinson's Disease
Posttraumatic Stress Disorder
Prader-Willi Syndrome
Rhetts Syndrome
Seizure Disorder
Sensory Integration Disorder
Smith-Lemli-Opitz syndrome
Smith-Magenis Syndrome
Spastic Paraparesis
Speech Impairment
Spina Bifida
Spinal Cord Injuries
Stroke
Traumatic Brain Injury
Van Buchems Disease
Visual Impairment
West Syndrome
Secondary Diagnosis
Please select...
Agenesis of the Corpus Collosum
Angelmans Syndrome
Apraxia
Asperger Syndrome
Attention Deficit Disorder (ADD)
Attention Deficit Hyperactivity Disorder (ADHD)
Auditory Processing Disorder
Autism
Brain Injuries
Cardiovascular
Cerebral Palsy
Chromosomal Disorder
Cognitive Delay
Communication Disorder
Congenital Anomaly
Cystic Fibrosis
Deafness
Developmental Delay
Down Syndrome
Dyslexia
Encephalopathy
Epilepsy
Failure to Thrive
Fetal Alcohol Syndrome
Gulf War Syndrome
Hearing Impairment
Hydrocephalus
Hypomylenation
Hypotonia
Intellectual Disability
Learning Disabilities
Medulloblastoma
Metatropic Dysplasia
Microcephaly
Mitochondrial Disease
Multiple Sclerosis
Muscular Dystrophy
Obsessive - Compulsive Disorder
Oppositional Defiant Disorder
Other
Parkinson's Disease
Posttraumatic Stress Disorder
Prader-Willi Syndrome
Rhetts Syndrome
Seizure Disorder
Sensory Integration Disorder
Smith-Lemli-Opitz syndrome
Smith-Magenis Syndrome
Spastic Paraparesis
Speech Impairment
Spina Bifida
Spinal Cord Injuries
Stroke
Traumatic Brain Injury
Van Buchems Disease
Visual Impairment
West Syndrome
If other, please provide detail
Ambulation
Please select...
Braces
Independent
Supported
Walker
Wheelchair
Communication
Please select...
Verbal
Assisting Device
Sign Language
Non-verbal / Limited Verbal Expression
Balance (majority of the time)
Please select...
Well Balanced
Impaired Balance
Seizure Information
Please select...
N/A - Does not experience siezures
Well controlled with medication
Not controlled with medication
Behavior Information
Please select...
Compliant
Oppositional
Easily Frustrated / Upset
Fearful
Physician's Name
Physician's Phone
Date of Last Tetanus shot:
What is the greatest challenge / goal that you hope to address with therapeutic riding?
Availability
Monday 9am - 12:00pm
Monday 12pm -5:00pm
Monday 5pm -8:00pm
Tuesday 9am - 12:00pm
Tuesday 12pm -5:00pm
Tuesday 5pm -8:00pm
Wednesday 9am - 12:00pm
Wednesday 12pm -5:00pm
Wednesday 5pm -8:00pm
Thursday 9am - 12:00pm
Thursday 12pm -5:00pm
Thursday 5pm -8:00pm
Friday 9am - 12:00pm
Friday 12pm -5:00pm
Saturday 9am - 12:00pm
Saturday 12pm -5:00pm
Previous Riding Experience
Name of Stables
Previous Riding Experience?
Yes
No
Style of riding
Please select...
English
Western
Other
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x
How long?
Location
Referral
How did you find out about ManeGait?
Contact Information
