Hippotherapy Interest Form

Hippotherapy Interest Form
Please fill out the form below if you are interested in learning more about hippotherapy.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Gender
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Emergency Contact
Emergency Contact Name
First NameLast Name
Relationship to Participant
Phone Number
Please enter a valid phone number.
Have you had any previous experience with horses?
YesNo
What specific goals or outcomes are you hoping to achieve through hippotherapy?
Are there any specific fears or concerns related to participating in hippotherapy?
Preferred Days and Times for Sessions
Additional Comments or Questions
Agreement and Consent:
By signing below, I acknowledge that I have provided accurate information to the best of my knowledge and give consent to participate in hippotherapy sessions.
Date
MonthDayYear
Date
Signature
Clear
Should be Empty:

Emergency Contact