GaitWay Workshop Registration Form

ManeGait Therapeutic Horsemanship

GaitWay to the Brain Training Workshop

Sunday, October 25th- Monday, October 26th.

Contact Information

First Name

Middle Name

Last Name

PATH # (if applicable)

Email Address

Street Address

City

State

Zip

Contact Phone Number:

Therapeutic Center Affiliation (if applicable)

Certifications:

Hold ctrl button to select more than one

If other, please specify

Reimbursement Policy: In instances of last minute emergency medication situations, a physician's letter must be provided for an exception refund. A $25 office fee will be retained

Please register me for the workshop:

$400.00

Payment options (registration is not complete until payment is received):

Credit Card - upon submission of this form a link will be provided to a secure payment processor Check - please mail your check to: ManeGait 4261 E. University Dr. #30-253, Prosper, TX 75078Other - please contact Kristen Haterius at khaterius@manegait.org or 469.387.5520

Contact Information