Application Form

General Information

(Parent to fill out)

Participant's Name

First Last

Email Address

Enter Email Confirm Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Phone

Age

Height

Weight

Gender

M

F

Employer/School

Parent(s)/Legal Guardian(s)

Caregivers

Phone

Referred by

Phone

How did you hear about the program?

Health History

(Physician fill out)

Diagnosis

Date of onset

Given the above diagnosis and medical information, this person is not medically precluded from participation in equine-assisted activities. I understand that Shoulder to Shoulder Ranch will weigh the medical information given against the existing precautions and contraindications. Therefore I refer this person to Shoulder to Shoulder Ranch for on-going evaluation to determine eligibility for participation.

Name/Title

Title

MD

DO

APRN

PA

Other

Signature

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

License/UPIN Number

Participant’s Application and Health History

General Information

Health History

Please indicate current or past special needs in the following areas

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