Rider Information Form
Please submit the following, or if you prefer, download the .pdf form, print and mail to:
Northland Therapeutic Riding Center
P.O. Box 1267
Kearney, MO 64060
Rider's Application and Health History
(To be completed by the rider or parent/legal guardian.)
Rider's Name:
DOB: Age: Height: Weight: Sex: M F
Home Address:
City: State: Zip: County:
Phone: Alternative #: Email:
Rider's Employer or School Name (if applicable):
Address: Phone:
Name of Parent/Legal Guardian (if participant is under 18 years of age):
Parent/Legal Guardian Address/Phone (if different from rider's address above):
Address:
City: State: Zip:
Phone: Email:
Please indicate current or past difficulties in the following systems/areas:
What medications are you currently taking, including over-the-counter medications?
Describe your abilities/difficulties in the following areas (including assistance required or equipment needed):
FUNCTION (i.e. Mobility skills such as transfers, walking, wheelchair use, driving/bus riding)
SOCIAL (i.e. Work/school including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc.)
GOALS (i.e. What would you like to accomplish through your participation in a therapeutic riding program?)
Signature of Rider or Parent/Legal Guardian:
Date:
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