Rider Information

Please tell us a little bit more about who is interested in riding at MiraclesTRC.

Rider First Name

Rider Last Name

Rider Preferred Name

Preferred Pronouns

Birthday

Month

Day

Year

Gender

Height (feet)

Height (inches)

Weight (in pounds)

School Name

Parent/Guardian Name(s)

Parent/Guardian/Rider's Employer

How did you hear of our porgram?

Contact Information

Preferred Contact First Name

Preferred Contact Last Name

Relationship to Rider

Preferred Phone

Preferred Email

Preferred Contact Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Alternate Contact First Name

Alternate Contact Last Name

Alternate Phone

Alternate Email

Alternate Contact Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Rider Goals

Please describe limitations/concerns in the area of physical function (e.g., ambulation, motor skills, balance, strength, tone, vision):

Please describe limitations/concerns in the areas of cognition and processing (e.g., attention, touch/sensation, memory, speech and language, sensory integration, learning disabilities, developmental delays):

Please describe limitations/concerns in the areas of psychological, emotional, behavioral, and social issues:

Previous Riding Experience

Please describe previous riding experience if applicable:

What are your/your rider's goals for this program? What specifically, do you want us to work on? (Examples may include balance, strength, tone, sensory, emotional issues, etc.)