Application form ONLINE PARTICIPANT/RIDER REGISTRATION FORM Participant Name* First Last Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth* Date Format: MM slash DD slash YYYY Weight*Height*Gender* Male Female Non Gender Specific School/Employer*Parent/Legal Guardian Name First Last Address (if different from above) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Address (Email is our primary form of communitcation)* Enter Email Confirm Email I do not have email access, please contact me viaDiagnosis or Disabling Condition*Primary DiagnosisSecondary DiagnosisOther Describe participant's previous riding experience and current level of riding*Describe participant's horseback riding goals or other program goals*What specific physical, cognitive and/or emotional goals do you have for your participant*How did you hear about REINS*Participant Scheduling: Please indicate days or times that are preferred by you and your participant. If there are times and days that you are unavailable please indicate that as well.*I understand that is a pre-registration form only. Full registration forms and medical packets will be sent to participants and need to be completed and returned by the dates indicated in the packet to participate in the program.* I understand I do not understand please contact me Form completed by*Date Submitted* Date Format: MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.