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    Therapeutic Riding Registration

    Please fill out this form and we will contact you within two business days to gather more information. If you have any questions, please feel free to contact us.

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    Name

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    Date of Birth

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    Phone Number

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    Email

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    Age

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    Mental Age

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    Approximate Weight

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    Parent or Guardian (if a minor)

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    General Disability

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    Check Where Appropriate

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    Ambulatory
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    Tactile Defensive
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    Visually Impaired
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    Uses Sign Language
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    Non-Ambulatory
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    Tight Adductors
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    Hearing Impaired
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    Verbal
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    Walks with Assistance
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    Able to bear weight
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    Seizures
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    Non-verbal
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    Able to maintain sitting position without support
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    Does Rider Have/Use

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    Shunt
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    Braces
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    Walker
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    Wheelchair
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    Hearing Aids
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